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PATIENT:REASON FOR ENCOUNTER:HISTORY OF PRESENT ILLNESS:PAST MEDICAL HISTORY:SOCIAL HISTORY:MEDICATIONS:ALLERGIES:

 Carolina Spencer

 

 Assistance with tracheostomy management.

 

 The patient is a 73-year-old female admitted to McGraw Hospital on July 17th with acute ischemic CVA and DKA. The patient has a very complicated medical history, including respiratory failure, on prolonged mechanical ventilation. She underwent tracheostomy placement on July 19th and was weaned from mechanical ventilation within 12 hours. She was also diagnosed with hospital-acquired pneumonia, multi-organism, and pulmonary embolism by CTPA. She is currently on heparin drip, while started on Warfarin. She also has end-stage renal disease and is on hemodialysis.

 

 In addition to the above, the patient was found to have some type of intracardiac shunt per echocardiogram, not otherwise defined; atherosclerosis of the internal carotid arteries; positive lupus anticoagulants; and long-standing history of diabetes mellitus, type II.

 

 Tobacco and alcohol use are unknown.

 

 Sliding scale insulin, Reglan, Lantus insulin, diltiazem, Timentin, heparin drip, Warfarin, Bactrim, Pepcid, and iron sulfate.

 

 No known allergies.

 

REVIEW OF SYSTEMS: Not available.

 

FAMILY HISTORY: Not available.

 

PHYSICAL EXAMINATION:

 

GENERAL: She is an unresponsive female, in no acute distress.

 

VITAL SIGNS: Temperature is 98.6 degrees; respiratory rate is 21 to 25, somewhat irregular; pulse is 102; blood pressure is 122/80; and pulse oximetry is 97% on 50% cuffless tracheostomy.

 

HEENT: Unable to visualize posterior pharynx secondary to the patient's resistance to mouth opening. The patient does have some natural dentition anteriorly. No coating of the tongue is appreciated. The patient has an eschar on the left upper lip, presumably secondary to ET tube. Conjunctivae are clear. Gaze is conjugate. The patient has a size 8 Portex cuffless tracheostomy tube in the midline.

 

CHEST: The patient has a few crackles at the right base, few anterior coarse rhonchi. No wheeze or stridor with the tracheostomy tube, patent. With finger occlusion of the cuffless #8 Portex, the patient does have stridor and increased respiratory rate. Unable to adequately percuss the chest.

 

CARDIOVASCULAR: The patient has regular rate and rhythm. No murmur or gallop is appreciated. No heaves or thrills.

 

ABDOMEN: Soft and obese. The patient has G-tube in position and normoactive bowel sounds. No guarding.

 

EXTREMITIES: She has decreased pulse in lower extremities bilaterally. No discrepancy in calf size is appreciated. No clubbing, cyanosis, or edema.

 

NEUROLOGIC: The patient does withdraw, on the left side; grimaces to pain. She is not cooperative with exam at this time.

 

LABORATORY DATA: BUN 16 and creatinine 3.3 on July 18th with venous CO2 of 24, calcium 9.1, white count 9200, hemoglobin 9.2, and platelets 515,000. Chest x-ray is not available for review.

 

IMPRESSION: The patient is a 73-year-old female, status post respiratory failure, prolonged mechanical ventilation, necessitating tracheostomy tube placement. She has had multiple complications including pulmonary embolism, for which she is now anticoagulated with heparin and reportedly intracardiac shunt, which would help explain her Aa gradient. She also reported she had a right-sided cavitary lesion and had negative AFB on bronchoalveolar lavage.

 

RECOMMENDATIONS:

 

  1. Change to #8 Portex cuffless tracheostomy tube. Would not plan on downsizing, capping tracheostomy at this time secondary to poor patient cough, decreased mental status, and inability to protect airway. She does have some evidence with occlusion of the tracheostomy of possible upper airway obstruction, and so, if her ability to protect her airway improves, she may need evaluation of the upper airway before considering progressing toward decannulation as well.
  2. Repeat chest x-ray to evaluate right cavitary lesion and obtain films from the primary care physician for comparison.

 

 

Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices.

 

What is/are the correct diagnosis code(s)?

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