OUTPATIENT ICD-9 AND ICD-10-CM CODING

Medical Specialty: Respiratory - Pulmonary

Cystic fibrosis

Description:

A 10 years of age carries a diagnosis of cystic fibrosis

INTERVAL HISTORY:

The patient is 10 years of age and carries a diagnosis of cystic fibrosis, seen in the clinic today for routine follow-up visit. He was accompanied by his adopted mother. He is attending the fourth grade and has not missed significant days for illness. He has a chronic cough that has been slightly increased for the prior 4 days. Sputum is not produced. Sinuses are described as clear. He is an eager eater, eating a regular diet of increased calorie and protein. He also was taking Resource just for kid juice boxes as well as chocolate milkmaid with half-and-half. Belly complaints are denied. He has 2 to 3 bowel movements per day. He does need a flu vaccine.

MEDICATIONS:

Albuterol premix via nebulizer as needed, albuterol MDI 2 puffs b.i.d., therapy Vest daily, Creon 20 two with meals and snacks, A-dec 2 tablets daily, Prevacid 15 mg daily, Advair 100/50 one inhalation twice daily, and MiraLax p.r.n.

PHYSICAL EXAMINATION:

VITAL SIGNS:

Respiratory rate 20 and pulse 91. Temperature is 100.0 per tympanic membrane. Oximetry is 98% on room air. Height is 128 cm, which is an increase of 1.0 cm from prior visit. Weight is 24.5 kg, which is an increase of 500 grams from prior visit.

GENERAL:

He is a cooperative school-aged boy in no apparent distress.

HEENT:

Tympanic membranes clear, throat with minimal postnasal drip.

CHEST:

Significant for 1+ hyperinflation. Lungs are auscultated with good air entry and clear breath sounds.

CARDIAC:

Regular sinus rhythm without murmur.

ABDOMEN:

Palpated as soft, without hepatosplenomegaly.

EXTREMITIES:

Not clubbed.

CHART REVIEW:

This chart was thoroughly reviewed prior to this conference by X, RN, BSN. Review of chart indicates that mother has good adherence to treatment plan indicated by medications being refilled in a timely fashion as well as clinic contact documented with appropriate concerns.

DISCUSSION:

PHYSICIAN:

X did note that mother reported that the patient had discontinued the Pulmozyme due to CCS reasons. He is not sure what this would be since CCS Pulmozyme is a covered benefit on CCS for children with cystic fibrosis. This situation will be looked into with the hope of restarting soon. Other than that the patient seems to be doing well. A flu shot was given.

NURSE:,/

X, RN, BSN, did note that the patient was doing quite well. Reinforcement of current medication regime was supplied. No other needs identified at this time.

RESPIRATORY CARE:

X, RCP, did review appropriate sequencing of medications with the patient and family. Once again, she was concerned the lack of Pulmozyme due to mom stating CCS issues. At this time, they have increased the Vest use to twice daily and are doing 30-minute treatments.

DIETICIAN:

X, RD, CDE, notes that the patient is 89% of his ideal body weight, which is a nutritional failure per cystic fibrosis guidelines. This is despite the fact that he has an excellent appetite. Mom reports he is taking his enzymes consistently as well as vitamins. He does have problems meeting his goal for resource drinks per day. Since the patient has been struggling to gain weight this past year, we will need to monitor his nutritional status and weight trend very closely. A variety of additional high calorie items were discussed with mom.

SOCIAL WORK:

X, LCSW, notes that mom has recently gradually from respiratory therapy school and has accepted a position here at Children's Hospital. The patient is doing well in school. With the exception of issues with CCS authorization, there appears to be no pressing social needs at this time.

IMPRESSION:

  • Cystic fibrosis.
  • Poor nutritional status.

PLAN:

  • Give flu vaccine 0.5 mg IM now, this was done.
  • Continue all other medications and treatment.
  • Evaluate/investigate rationale for no authorization of Pulmozyme with CCS.
  • Needs to augment current high-calorie diet to give more nutrition. To follow advice by a dietician.
  • Continue all the medication treatments before.
  • To continue off and ongoing psychosocial nutritional counseling as necessary.
  • 515, 269.8, V03.89; J84.10, E63.8, Z23; 90461, 90660
  • 514, 266.1, V06.6; J81.1, E53.1, Z23; 90460, 90662
  • 277.00, 269.9, V04.81; E84.9, E63.9, Z23; 90471, 90658
  • 277.09, 263.1, V07.2; E84.8, E44.1, Z41.8; 90473, 90669

Answer

Bronchitis

Description:

2-month-old female - increased work of breathing.

CHIEF COMPLAINT:

Increased work of breathing.

HISTORY OF PRESENT ILLNESS:

The patient is a 2-month-old female with a 9-day history of illness. Per mom's report, the illness started 9 days ago with a dry cough. The patient was eating normal up until approximately three days ago. Mom was using a vaporizer at night, which she feels to have helped. The patient's cough gradually worsened and three days ago, the patient had a significant increasing cough. At that time, the patient also had significant increasing congestion. Two days ago the patient was taken to the primary care physician's office and the patient was given Xopenex 2 puffs every 4 to 6 hours for home regimen, but this per mom's report, did not help the patient's symptoms. On Wednesday evening, the patient's congestion and work of breathing increased and the patient was gagging after feedings. The patient was brought to Children's Hospital Emergency Room at which time the patient was evaluated. A chest x-ray was obtained and was noted to be normal. The patient's saturations were noted to be normal and the patient was discharged home. Last night, the patient was having multiple episodes of emesis after feedings with coughing and today was noted to have decreasing activity. The patient had a 101 temperature on Wednesday evening, but has had no true fevers. The patient has had a mild decrease in urine output today and secondary to the persistent increased work of breathing, coughing, and posttussive emesis, the patient was brought to Children's Hospital for reevaluation.

REVIEW OF SYSTEMS:

The remainder of the review of system is otherwise negative, all systems being reviewed, outside of pertinent positives as stated above.

ALLERGIES:

NO KNOWN DRUG ALLERGIES.

MEDICATIONS:

As above.

IMMUNIZATIONS:

None.

PAST MEDICAL HISTORY:

No hospitalizations. No surgeries.

BIRTH HISTORY:

The patient was born to a G8, P2, A6 mom via normal spontaneous vaginal delivery. Birth weight 6 pounds 12 ounces. Mom stated she had a uterine infection during her pregnancy and at the time of delivery, but the patient was only in the hospital for 24 hours with mom after delivery. The patient was full term and mom was noted to have gestational diabetes controlled with diet during her pregnancy.

FAMILY HISTORY:

Brother, mother, and father all have asthma. Mom was noted to have gestational diabetes.

SOCIAL HISTORY:

The patient lives with mother, father, and a brother. There is one bird. There are smokers in the household. There are sick contacts.

PHYSICAL EXAMINATION:

VITAL SIGNS:

Temperature is 97.7 and pulse is 181, but the patient is fussy. Respiratory rate ranged between 36 and 44. The patient is saturating 100% on one-half liter and 89% on room air.

GENERAL APPEARANCE:

Nontoxic child, but with increased work of breathing. No respiratory distress.

HEENT:

Head is normocephalic and atraumatic. Anterior fontanelle flat. Pupils are equal, round, and reactive to light bilaterally. Tympanic membranes are clear bilaterally. Nares are congested. Mucous membranes are moist without erythema.

NECK:

Supple. No lymphadenopathy.

CHEST:

Exhibits symmetric expansion and retractions.

LUNGS:

The patient has diffuse crackles bilaterally, but no wheezes, rales, or rhonchi.

CARDIOVASCULAR:

Heart has a 2/6 vibratory systolic ejection murmur, best heard over the left sternal boarder.

ABDOMEN:,/

Soft, nondistended, and nondistended. Good bowel sounds noted in all 4 quadrants.

GU:

Normal female. No discharge or erythema.

BACK:

Normal with a normal curvature.

EXTREMITIES:

A 2+ pulses in the bilateral upper lower extremities. No evidence of clubbing, cyanosis, or edema. Capillary refill less than 3 seconds.

LABORATORY DATA:

Labs in the emergency room include a CBC, which showed a white blood cell count of 20.8 with a hemoglobin of 10.7, hematocrit of 31.3 with platelet count of 715,000 with 40% neutrophils, 2 bands, and 70% monocytes. A urinalysis obtained in the emergency room was noted to be negative. CRP was noted to be 2.0. The chest x-ray, reviewed by myself in the emergency room, showed no significant change from previous x-ray, but the patient does has some bronchial wall thickening.

ASSESSMENT AND PLAN:

This is a 2-month-old female who presents to Children's Hospital with examination consistent with bronchitis. At this time, the patient will be placed on the bronchitis pathway providing this patient with aggressive suctioning and supplemental oxygen as needed. Currently, at this time, I feel no respiratory treatments are indicated in this patient. I hear no evidence of wheezing or reactive airway disease. We will continue to monitor and reassess this patient closely for this as there is a strong family history of reactive airway disease; however, at this time, the patient will be monitored without any medications and the remainder of the clinical course will be determined by her presentation during the course of this illness.

  • 466.0, V17.5; J20.9, Z82.5
  • 466.19, V18.2; J21.8, Z83.2
  • 464.4, V17.6; J05.0, Z83.6
  • 478.9, V12.69; J39.8, Z87.09

Answer

Interstitial disease secondary to lupus pneumonitis

Description:

Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis.

SUBJECTIVE:

The patient returns to the Pulmonary Medicine Clinic for followup evaluation of interstitial disease secondary to lupus pneumonitis. She was last seen in the Pulmonary Medicine Clinic in January 2004. Since that time, her respiratory status has been quite good. She has had no major respiratory difficulties; however, starting yesterday she began with increasing back and joint pain and as a result a deep breath has caused some back discomfort. She denies any problems with cough or sputum production. No fevers or chills. Recently, she has had a bit more problems with fatigue. For the most part, she has had no pulmonary limitations to her activity.

CURRENT MEDICATIONS:

Synthroid 0.112 mg daily; Prilosec 20 mg daily; prednisone, she was 2.5 mg daily, but discontinued this on 06/16/2004; Plaquenil 200 mg b.i.d.; Imuran 100 mg daily; Advair one puff b.i.d.; Premarin 0.3 mg daily; Lipitor 10 mg Monday through Friday; Actonel 35 mg weekly; and aspirin 81 mg daily. She is also on calcium, vitamin D, vitamin E, vitamin C and a multivitamin.

ALLERGIES:

Penicillin and also intolerance to shellfish.

REVIEW OF SYSTEMS:

Noncontributory except as outlined above.

EXAMINATION:

General:

The patient was in no acute distress.

Vital signs:

Blood pressure 122/60, pulse 72 and respiratory rate 16.

HEENT:

Nasal mucosa was mild-to-moderately erythematous and edematous. Oropharynx was clear.

Neck:

Supple without palpable lymphadenopathy.

Chest:

Chest demonstrates decreased breath sounds, but clear.

Cardiovascular:

Regular rate and rhythm.

Abdomen:

Soft and nontender.

Extremities:

Without edema. No skin lesions.

O2 saturation was checked at rest. On room air it was 96% and on ambulation it varied between 94% and 96%. Chest x-ray obtained today showed mild increased interstitial markings consistent with a history of lupus pneumonitis. She has not had the previous chest x-ray with which to compare; however, I did compare the markings was less prominent when compared with previous CT scan.

ASSESSMENT:

  • Lupus with mild pneumonitis.
  • Respiratory status is stable.
  • Increasing back and joint pain, possibly related to patient's lupus, however, in fact may be related to recent discontinuation of prednisone.

PLAN:

At this time, I have recommended to continue her current medications. We would like to see her back in approximately four to five months, at which time I would like to recheck her pulmonary function test as well as check CAT scan. At that point, it may be reasonable to consider weaning her Imuran if her pulmonary status is stable and the lupus appears to be under control.

  • 710.0, 719.99, 724.2; M32.10, M25.9, M54.5
  • 710.0, 517.8, 719.49, 724.5; M32.13, M25.50, M54.9
  • 420.0, 517.8, 719.50, 724.3; M32.12, J99, M25.60, M54.30
  • 710.1, 517.8, 719.48, 724.5; M34.0, M25.50, M54.89

Answer

Subglottic stenosis - Direct laryngoscopy and bronchoscopy

Description:

Direct laryngoscopy and bronchoscopy.

PREOPERATIVE DIAGNOSIS:

Subglottic stenosis.

POSTOPERATIVE DIAGNOSIS:

Subglottic stenosis.

OPERATIVE PROCEDURES:

Direct laryngoscopy and bronchoscopy.

ANESTHESIA:

General inhalation.

DESCRIPTION OF PROCEDURE:

The patient was taken to the operating room and placed supine on the operative table. General inhalational anesthesia was administered through the patient's tracheostomy tube. The small Parsons laryngoscope was inserted and the 2.9-mm telescope was used to inspect the airway. There was an estimated 60-70% circumferential mature subglottic stenosis that extended from just under the vocal folds to approximately 3 mm below the vocal folds. The stoma showed some suprastomal fibroma. The remaining tracheobronchial passages were clear. The patient's 3.5 neonatal tracheostomy tube was repositioned and secured with Velcro ties. Bleeding was negligible. There were no untoward complications. The patient tolerated the procedure well and was transferred to recovery room in stable condition.

  • 784.1, V46.0; R07.0, Z99.0; 31622
  • 478.6, V46.2; J38.4, Z99.81; 31630
  • 786.30, V46.8; R04.9, Z99.89; 31502
  • 478.74, V44.0; J38.6, Z93.0; 31615

Answer

Left hemothorax - Thoracentesis

Description:

Thoracentesis. Left pleural effusion. Left hemothorax.

PREOPERATIVE DIAGNOSIS:

Left pleural effusion.

POSTOPERATIVE DIAGNOSIS:

Left hemothorax.

PROCEDURE:

Thoracentesis.

PROCEDURE IN DETAIL:

After obtaining informed consent and having explained the procedure to the patient, he was sat at the side of a stretcher in the emergency department. His left back was prepped and draped in the usual fashion. Xylocaine 1% was used to infiltrate his chest wall and the chest entered upon the ninth intercostal space in the midscapular line and the thoracentesis catheter was used and placed, and then we proceed to draw by hand about 1200 mL blood. This blood was nonclotting and it was tested twice. Halfway during the procedure, the patient felt that he was getting dizzy and his pressure at that time had dropped to the 80s. Therefore, we laid him off his right side while keeping the chest catheter in place. At that time, I proceeded to continuously draw fluids slowly and then when the patient recovered we sat him up again and we proceed to complete the procedure.

Overall besides the described episode, the patient tolerated the procedure well and afterwards, we took another chest x-ray that showed much improvement in the pleural effusion and at that particular time, with all the history we proceeded to admit the patient for observation and with an idea to obtain a CT in the morning to see whether the patient would need an pigtail intrapleural catheter or not.

  • 511.0; J94.9; 32654
  • 511.89; J86; 32650
  • 511.89; J94.2; 32554
  • 513.0; J85.2; 32601

Answer

Pneumonia

Description:

A 23-month-old girl has a history of reactive airway disease, is being treated on an outpatient basis for pneumonia, presents with cough and fever.

CHIEF COMPLAINT AND IDENTIFICATION:

A is a 23-month-old girl, who has a history of reactive airway disease who is being treated on an outpatient basis for pneumonia who presents with cough and fever.

HISTORY OF PRESENT ILLNESS:

The patient is to known to have reactive airway disease and uses Pulmicort daily and albuterol up to 4 times a day via nebulization.

She has no hospitalizations.

The patient has had a 1 week or so history of cough. She was seen by the primary care provider and given amoxicillin for yellow nasal discharge according to mom. She has been taking 1 teaspoon every 6 hours. She originally was having some low-grade fever with a maximum of 100.4 degrees Fahrenheit; however, on the day prior to admission, she had a 104.4 degrees Fahrenheit temperature, and was having posttussive emesis. She is using her nebulizer, but the child was in respiratory distress, and this was not alleviated by the nebulizer, so she was brought to Children's Hospital Central California.

At Children's Hospital, the patient was originally treated as an asthmatic and was receiving nebulized treatments; however, a chest x-ray did show right-sided pneumonia, and the patient was hypoxemic after resolution of her respiratory distress, so the Hospitalist Service was contacted regarding admission. The patient was seen and admitted through the emergency room.,/

REVIEW OF SYSTEMS:

Negative except that indicated in the history of present illness. All systems were checked.

PAST MEDICAL HISTORY:

,p> As stated in the history of present illness, no hospitalizations, no surgeries.

IMMUNIZATIONS:

The patient is up-to-date on her shots. She has a schedule for her 2 year-old shot soon.

ALLERGIES:

No known drug allergies.

DEVELOPMENT HISTORY:

Developmentally, she is within normal limits.

FAMILY HISTORY:

Her maternal uncles have asthma. There are multiple family members on the maternal side that have diabetes mellitus, otherwise the family history is negative for other chronic medical conditions.

SOCIAL HISTORY:

Her sister has a runny nose, but no other sick contacts. The family lives in Delano. She lives with her mom and sister. The dad is involved, but the parents are separated. There is no smoking exposure.

PHYSICAL EXAMINATION:

GENERAL:

The child was in no acute distress.

VITAL SIGNS:

Temperature 99.8 degrees Fahrenheit, heart rate 144, respiratory rate 28. Oxygen saturations 98% on continuous. Off of oxygen shows 85% laying down on room air. The T-max in the ER was 101.3 degrees Fahrenheit.

SKIN:

Clear.

HEENT:

Pupils were equal, round, react to light. No conjunctival injection or discharge. Tympanic membranes were clear. No nasal discharge. Oropharynx moist and clear.

NECK:

Supple without lymphadenopathy, thyromegaly, or masses.

CHEST:

Clear to auscultation bilaterally; no tachypnea, wheezing, or retractions.

CARDIOVASCULAR:

Regular rate and rhythm. No murmurs noted. Well perfused peripherally.

ABDOMEN:

Bowel sounds are present. The abdomen is soft. There is no hepatosplenomegaly, no masses, nontender to palpation.

GENITOURINARY:

No inguinal lymphadenopathy. Tanner stage I female.

EXTREMITIES:

Symmetric in length. No joint effusions. She moves all extremities well.

BACK:

Straight. No spinous defects.

NEUROLOGIC:

The patient has a normal neurologic exam. She is sitting up solo in bed, gets on her knees, stands up, is playful, smiles, is interactive. She has no focal neurologic deficits.

LABORATORY DATA:

Chest x-ray by my reading shows a right lower lobe infiltrate. Metabolic panel: Sodium 139, potassium 3.5, chloride 106, total CO2 22, BUN and creatinine are 5 and 0.3 respectively, glucose 84, CRP 4.3. White blood cell count 13.7, hemoglobin and hematocrit 9.6 and 29.9 respectively, and platelets 294,000. Differential of the white count 34% lymphocytes, 55% neutrophils.

ASSESSMENT AND PLAN:

This is a 22-month-old girl, who has an infiltrate on the x-ray, hypoxemia, and presented in respiratory distress. I believe, she has bacterial pneumonia, which is partially treated by her amoxicillin, which is a failure of her outpatient treatment. She will be placed on the pneumonia pathway and started on cefuroxime to broaden her coverage. She is being admitted for hypoxemia. I hope that this will resolve overnight, and she will be discharged in the morning. I will start her home medications of Pulmicort twice daily and albuterol on a p.r.n. basis; however, at this point, she has no wheezing, so no systemic steroids will be instituted.

Further interventions will depend on the clinical course.

  • 485, 496, 799.01; J18.0, J44.9, R09.01
  • 480.0, 493.00, 786.09; J12.0, J45.20, R06.00
  • 486, 493.81, 786.05; J18.9, J45.990, R06.02
  • 482.9, 493.90, 799.02; J15.9, J45.909, R09.02

Answer

Short of breath

Description:

Patient is here to discuss possible open lung biopsy.

CHART NOTE:

She is here to discuss possible open lung biopsy that she has actually scheduled for tomorrow. Dr. XYZ had seen her because of her complaints of shortness of breath. Then she had the pulmonary function test and CT scan and he felt that she probably had usual interstitial pneumonitis, but wanted her to have an open lung biopsy so he had her see Dr. XYZ Estep. He had concurred with Dr. XYZ that an open lung biopsy was appropriate and she was actually scheduled for this but both Dr. XYZ and I were unavailable before the procedure was originally scheduled so he had it delayed so that she could talk with us prior to having the biopsy. She was ready to go ahead with this and felt that it was important she find out why she is short of breath. She is very concerned about the findings on her CAT scan and pulmonary function test. She seemed alarmed to report that Dr. XYZ had found that her lung capacity was reduced to 60% of what should be normal. However, I told her that two years ago Dr. XYZ did pulmonary function studies which showed the same change in function. And that really her pulmonary function test, at least compared from two years ago, had not really changed over this period of time. After discussing the serious nature of an open lung biopsy, the fact that her pulmonary function studies have not changed in two years, the fact that she likely has a number of other things that are contributing to her being out of breath, which is deconditioning and obesity, she seemed comfortable with the thought of simply monitoring this a little bit longer before undergoing something as risky as an open lung biopsy. In fact when I called Dr. XYZ to talk to him about cancelling the procedure, he stated he would be very uncomfortable with doing an open lung biopsy on someone with pulmonary function studies which had not changed. I also explained to patient that I did not think Dr. XYZ was aware that she had had pulmonary function studies two years previously and certainly did not know that there results of those. And also I spoke with Dr. XYZ who agreed that although the two different tests may have some minor differences accounting for some of the similarity in results that may or may not be completely accurate, that generally a person with progressive interstitial lung disease without a fairly substantial change on pulmonary function tests even if they were done at different facilities.

I had a 30-minute discussion with patient about all of this and showed her the different test results and had a lengthy talk with her about the open lung biopsy and she ultimately felt very uncomfortable with going ahead and decided to cancel it. I also told her we could continue to monitor her breathing problems and continue to monitor her CAT scan, x-ray, and pulmonary function tests. And if there was some sign that this was a progressive problem, she could still go ahead with the lung biopsy. But she needed to understand that the treatment and likely diagnosis found from an open lung biopsy were not highly likely to be of any great help to her. She understands that the diagnoses made from open lung biopsy are not all that specific and that the treatment for the few specific things that can be detected are not often well tolerated or extremely helpful.

We are going to see her back in a month to see how her breathing is doing. We will cancel her open lung biopsy for tomorrow and decide whether she should follow up with a pulmonologist at that time. She is encouraged to lose weight as this is certainly a contributing factor to her shortness of breath and overall state of health.

  • 786.05, 278.00, 794.2; R06.2, E66.9, R94.2
  • 786.01, 278.01, R94.30; R06.4, E66.01, 794.30
  • 786.1, 783.1, 794.7; R06.1, R63.5, R94.8
  • 786.09, 278.02, 794.02; R06.02, E66.3, R94.01

Answer

Pneumothorax and subcutaneous emphysema

Description:

Consult for subcutaneous emphysema and a small right-sided pneumothorax.

REASON FOR CONSULTATION:

Pneumothorax and subcutaneous emphysema.

HISTORY OF PRESENT ILLNESS:

The patient is a 48 year-old male who was initially seen in the emergency room on Monday with complaints of scapular pain. The patient presented the following day with subcutaneous emphysema and continued complaints of pain as well as change in his voice. The patient was evaluated with a CT scan of the chest and neck which demonstrated significant subcutaneous emphysema, a small right-sided pneumothorax, but no other findings. The patient was admitted for observation.

PAST SURGICAL HISTORY:

Hernia repair and tonsillectomy.

ALLERGIES:

Penicillin.

MEDICATIONS:

Please see chart.

REVIEW OF SYSTEMS:

Not contributory.

PHYSICAL EXAMINATION:

GENERAL:

Well developed, well nourished, lying on hospital bed in minimal distress.

HEENT:

Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact.

NECK:

Supple. Trachea is midline.

CHEST:

Clear to auscultation bilaterally.

CARDIOVASCULAR:

Regular rate and rhythm.

ABDOMEN:

Soft, nontender, and nondistended. Normoactive bowel sounds.

EXTREMITIES:

No clubbing, edema, or cyanosis.

SKIN:

The patient has significant subcutaneous emphysema of the upper chest and anterior neck area although he states that the subcutaneous emphysema has improved significantly since yesterday.

DIAGNOSTIC STUDIES:

As above.

IMPRESSION:

The patient is a 48 year-old male with subcutaneous emphysema and a small right-sided pneumothorax.

RECOMMENDATIONS:

At this time, the CT Surgery service has been consulted and has left recommendations. The patient also is awaiting bronchoscopy per the Pulmonary Service. At this time, there are no General Surgery issues.

  • 511.89, 518.2; J94.2, J98.3
  • 512.1, 518.0; J95.811, J98.11
  • 512.89, 518.1; J93.9, J98.2
  • 512.81, 518.0; J93.11, J98.19

Answer

Coughing and wheezing

Description:

Patient with complaints of significant coughing and wheezing.

Thank you very much for referring Mr. Y for pulmonary evaluation. As you know, he is an 85 year-old man who has been referred for complaints of significant coughing and wheezing. The patient was originally seen on 15/02/2008. At that time he was complaining of the same symptoms. The patient had a respiratory evaluation six months ago that was reported to be okay but he still complains of still some difficulty at the time of swallowing. His followup today was done after the patient underwent initial swallowing evaluation. He is still complaining of cough, wheezing, and congestion.

PAST MEDICAL HISTORY:

Unremarkable, except for atherosclerotic vascular disease.

ALLERGIES:

PENICILLIN.

CURRENT MEDICATIONS:

Include Seroquel, Flomax, and Nexium.

PAST SURGICAL HISTORY:

Appendectomy and exploratory laparotomy.

FAMILY HISTORY:

Noncontributory.

SOCIAL HISTORY:

The patient is a non-smoker. No alcohol abuse. The patient is married with no children.

REVIEW OF SYSTEMS:

Significant for an old CVA.

PHYSICAL EXAMINATION:

The patient is an elderly male alert and cooperative. Blood pressure 96/60 mmHg. Respirations were 20. Pulse 94. Afebrile. O2 was 94% on room air.

HEENT:

Normocephalic and atraumatic. Pupils are reactive. Oral mucosa is grossly normal. Neck is supple. Lungs: Decreased breath sounds. Disturbed breath sounds with poor exchange. Heart: Regular rhythm.

Abdomen:

Soft and nontender. No organomegaly or masses.

Extremities:

No cyanosis, clubbing, or edema.

LABORATORY DATA:

Oropharyngeal evaluation done on 11/02/2006 revealed mild oropharyngeal dysphagia with no evidence of laryngeal penetration or aspiration with food or liquid. Slight reduction in tongue retraction resulting in mild residual remaining in the palatal sinuses, which clear with liquid swallow and double-saliva swallow.

ASSESSMENT:

  • Cough probably multifactorial combination of gastroesophageal reflux and recurrent aspiration.
  • Old CVA with left dominant side hemiparesis.
  • Oropharyngeal dysphagia.

PLAN:

At the present time, the patient is recommended to continue on a regular diet, continue speech pathology evaluation as well as perform double-swallow during meals with bolus sensation. He may use Italian lemon ice during meals to help clear sinuses as well. The patient will follow up with you. If you need any further assistance, do not hesitate to call me.

  • 786.2, 530.81, 438.21, 787.22; R05, K21.9, I69.952, R13.12
  • 786.1, 530.0, 438.21, 787.20; R06.1, K22.0, I69.951, R13.10
  • 784.99, 530.5, 438.82, 787.24; R06.5, K22.0, I69.991, R13.14
  • 786.05, 530.85, 438.83, 787.20; R06.2, K22.70, I69.992, R13.0

Answer

Fifth disease with sinusitis

Description:

Fifth disease with sinusitis.

SUBJECTIVE:

Grandfather brings the patient in today because of headaches, mostly in her face. She is feeling pressure there with a lot of sniffles. Last night, she complained of sore throat and a loose cough. Over the last three days, she has had a rash on her face, back and arms. A lot of fifth disease at school. She says it itches and they have been doing some Benadryl for this. She has not had any wheezing lately and is not taking any ongoing medications for her asthma.

PAST MEDICAL HISTORY:

Asthma and allergies.

FAMILY HISTORY:

Sister is dizzy but no other acute illnesses.

OBJECTIVE:

General:

The patient is an 11 year-old female. Alert and cooperative. No acute distress.

Neck:

Supple without adenopathy.

HEENT:

Ear canals clear. TMs, bilaterally, gray in color and good light reflex. Oropharynx is pink and moist. No erythema or exudates. She has postnasal discharge. Nares are swollen and red. Purulent discharge in the posterior turbinates. Both maxillary sinuses are tender. She has some mild tenderness in the left frontal sinus. Eyes are puffy and she has dark circles.

Chest:

Respirations are regular and nonlabored.

Lungs:

Clear to auscultation throughout.

Heart:

Regular rhythm without murmur.

Skin:

Warm, dry and pink. Moist mucous membranes. Red, lacey rash from the wrists to the elbows, both sides. It is very faint on the lower back and she has reddened cheeks, as well.

ASSESSMENT:

Fifth disease with sinusitis.

PLAN:

Omnicef 300 mg daily for 10 days. May use some Zyrtec for the itching. Samples are given.

  • 058.10, 461.9; B08.20, J01.90
  • 057.8, 462; L44.4, J02.8
  • 698.9, 461.8; L29.9, J01.81
  • 057.0, 461.8; B08.3, J01.80

Answer