Root Operation Examples Answers

 ICD-10-PCS Root Operation Test Answers

ICD-10-PCS Practice Questions Answers: 

Inpatient Coding Practice Questions Answers:

Root Operations to Take Out Some or All of a Body Part

1.    0D5P8ZZ

2.    0DTN0ZZ

3.    0Y6Y0Z0

4.    0UB04ZZ

5.    0UDB7ZX

6.    07DR3ZX

7.    0DB68ZX

8.    0SB40ZZ

9.    0BTG0ZZ

10. 0VB08ZZ

11. 0VT00ZZ

12. 0U5B4ZZ

13. 0Y670ZZ

14. 0Y6C0Z3

15. 095KXZZ

Root Operation Examples

 ICD-10-PCS Root Operation Test 

ICD-10-PCS Practice Questions: 

Inpatient Coding Practice Questions.

Root Operations to Take Out Some or All of a Body Part

 

Excision, Resection, Detachment, Destruction, and Extraction

 

1.    Sigmoidoscopy with rectal polyp fulguration

Root Operation – Destruction

  

2.    Laparotomy with complete removal of sigmoid colon

Root Operation – Resection 

 

3.    Left 5^th toe ray amputation at the metatarsal-phalangeal joint

Root Operation – Detachment 

 

4.    Laparoscopic removal of right ovarian cyst

Root Operation – Excision 

 

5.    Diagnostic dilatation and curettage

Root Operation – Extraction 

 

6.    Bone marrow aspiration left iliac crest

Root Operation – Extraction 

 

7.    EGD with gastric biopsy

Root Operation – Excision 

 

8.    L5-S1 discectomy via laminotomy with moderate-sized fragments retrieved

Root Operation – Excision 

 

9.    Left upper lobectomy of lung via thoractom

Root Operation – Resection 

 

10.  TURP (transurethral resection of prostate)

Root Operation – Excision 

 

11.  Open retropubic prostatectomy

Root Operation – Resection

  

12.  Laparoscopic endometrial ablation

Root Operation – Destruction

  

13.  Revision of right BKA to AKA

Root Operation – Detachment

  

14.  Amputation above right knee, distal shaft of femur (Definition of Low:  Amputation at the distal portion of the shaft of the humerus or femur)

Root Operation – Detachment

 

 15.  Cauterization of nosebleed

Root Operation – Destruction

 

 

Selection of Principal Dx

Inpatient coding Pdx/Principal diagnosis guidelines.

 Principal Diagnosis

Often, instructions in the code book, or other official guideline, provide sequencing direction even though multiple conditions may meet the definition of Principal Diagnosis.

 Be mindful of: 

1.       Uniform Hospital Discharge Data Set (UHDDS) definition

2.       Chapter-Specific guidelines

3.       Uncertain Diagnoses

4.       Two or more diagnoses

 

Selection of Principal Diagnosis 

The circumstances of inpatient admission always govern the selection of principal diagnosis.

The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.”

 

Principal Diagnosis: Uncertain Diagnosis 

Official Guideline: If the [principal] diagnosis documented at the time of discharge is qualified as ‘probable’, ‘suspected’, ‘likely’, ‘questionable’, ‘possible’, ‘still to be ruled out’, or other similar terms indicating uncertainty, code the condition as if it existed or was established.

 Remember to distinguish between ‘Rule out’ diagnoses versus ‘Ruled out’ diagnoses

 

Principal Diagnosis: Two or More Diagnoses 

Official Guideline: In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis, as determined by the circumstances of admission, diagnostic workup, and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first. 

This rule now applies to a symptom followed by two or more comparative or contrasting diagnoses. Code the comparative/contrasting diagnoses, do NOT code the symptom.

A symptom(s) followed by contrasting/comparative diagnoses

GUIDELINE HAS BEEN DELETED EFFECTIVE OCTOBER 1, 2014

 The Official Guideline for two conditions as Principal Diagnosis is much more strictly defined than both conditions merely being present at the time of admission.

 It is always inappropriate to base coding decisions solely on reimbursement or public reporting implications.

  

PDX: Two or More Diagnoses – Tips 

Present on admission does not equal reason for admission 

Look at what condition appears to be most closely related to the signs, symptoms and other findings that were noted on admission 

Reason for presentation to the Emergency Department is not always the reason for inpatient admission 

One condition may have necessitated inpatient admission, while the other may have been manageable in the outpatient setting

 Chronic conditions and/or acute conditions, may be incidental to the reason for admission

These should not be reported as principal diagnosis

 For patients transferred into our facilities, be sure to identify the reason for the transfer

Usually, it is due to the fact that the level of service needed by the patient could not be performed at the originating facility

 

Sequencing

 Objectively evaluate the circumstances of admission and sequence accordingly.

 Review physician’s workup and treatment provided – it may be that the two conditions are not as equal as they initially appeared.

 It may be that one condition necessitated admission while the other could have been worked up and treated as an outpatient.

Inpatient Sample Chart 2 ED

  Inpatient sample charts / Sample Inpatient cases / Inpatient DRG coding / DRG coding sample charts

EMERGENCY DEPARTMENT

History of Present Illness

The patient presents with difficulty breathing.  The onset was 2 days ago.  The course/duration of symptoms is worsening.  Degree at onset mild.  Degree at present moderate.  The Exacerbating factors is exertion.  The Relieving factors is rest.  Risk factors consist of asthma.  Prior episodes: rare.  Therapy today: beta-agonist albuterol and doctor's office visit.  Associated symptoms: chest pain and cough.  Additional history: Pt was seen at her physician's office, found to have an O2 saturation of 85% on room air, and was sent to the ED..  

 

Review of Systems

Constitutional symptoms:  Negative except as documented in HPI.

Skin symptoms:  Negative except as documented in HPI.

Eye symptoms:  Negative except as documented in HPI.

ENMT symptoms:  Negative except as documented in HPI.

Respiratory symptoms:  Negative except as documented in HPI.

Cardiovascular symptoms:  Negative except as documented in HPI.

Gastrointestinal symptoms:  Negative except as documented in HPI.

Genitourinary symptoms:  Negative except as documented in HPI.

Musculoskeletal symptoms:  Negative except as documented in HPI.

Neurologic symptoms:  Negative except as documented in HPI.

Psychiatric symptoms:  Negative except as documented in HPI.

Endocrine symptoms:  Negative except as documented in HPI.

Hematologic/Lymphatic symptoms:  Negative except as documented in HPI.

Allergy/immunologic symptoms:  Negative except as documented in HPI.

          Additional review of systems information: All other systems reviewed and otherwise negative.

 

Health Status

Allergies: 

Allergic Reactions (Selected)

Moderate

Azithromycin- Hives.

Keflex- Hives.

Penicillins- Hives..

Medications:  (Selected)

Documented Medications

Documented

Fetzima 120 mg oral capsule, extended release: 120 mg = 1 cap(s), Oral, Daily

ProAir HFA 90 mcg/inh inhalation aerosol: 2 puff(s), INH, q4hr, PRN: for wheezing

Singulair 10 mg oral tablet: 10 mg = 1 tab(s), Oral, qPM

amitriptyline 100 mg oral tablet: 200 mg = 2 tab(s), Oral, Once a day (at bedtime)

baclofen 20 mg oral tablet: 20 mg = 1 tab(s), Oral, TID

benzonatate 100 mg oral capsule: 100 mg = 1 cap(s), Oral, BID

busPIRone 15 mg oral tablet: 15 mg = 1 tab(s), Oral, TID

divalproex sodium 250 mg oral tablet, extended release: 750 mg = 3 tab(s), Oral, Once a day (at bedtime)

gabapentin 600 mg oral tablet: 600 mg = 1 tab(s), Oral, QID

hydrOXYzine hydrochloride 50 mg oral tablet: 50 mg = 1 tab(s), Oral, TID, PRN: for anxiety

hydroCHLOROthiazide 25 mg oral tablet: 25 mg = 1 tab(s), Oral, Daily

levothyroxine 150 mcg (0.15 mg) oral capsule: 150 mcg = 1 cap(s), Oral, Daily

meloxicam 15 mg oral tablet: 15 mg = 1 tab(s), Oral, Daily

pravastatin 20 mg oral tablet: 20 mg = 1 tab(s), Oral, Daily

ramelteon 8 mg oral tablet: 8 mg = 1 tab(s), Oral, Once a day (at bedtime)

tiZANidine 4 mg oral capsule: 4 mg = 1 cap(s), Oral, TID.

 

Past Medical/ Family/ Social History

Medical history: 

No active or resolved past medical history items have been selected or recorded..

Surgical history: 

Cesarean section

Arthroscopy of knee

FESS - Functional endoscopic sinus surgery

Hysterectomy  

Family history: 

No family history items have been selected or recorded..

Social history: 

Social & Psychosocial History

Social History

                Alcohol

                Denies Alcohol Use

 

                Substance Abuse

                Denies Substance Abuse

                Never

 

                Tobacco

                High Risk

                10 or more cigarettes (1/2 pack or more)/day in last 30 days Tobacco Use:.  3/4 pack per day.  15 year(s).

                10 or more cigarettes (1/2 pack or more)/day in last 30 days Tobacco Use:.

 

                Electronic Cigarette/Vaping

                Denies Electronic Cigarette Use

                Electronic Cigarette Use: Never.

 

Psychosocial History

                No active psychosocial history has been recorded.

Problem list: 

Active Problems (8)

Anxiety and depression

Chronic back pain

Colitis

Hyperlipidemia

Hypertension

Migraine

Multiple sclerosis

Osteoarthritis

General:  Alert, moderate distress. 

Skin:  Warm, dry, intact. 

Head:  Normocephalic, atraumatic. 

Neck:  Supple.

Eye:  Extraocular movements are intact.

Ears, nose, mouth and throat:  Oral mucosa moist.

Cardiovascular:  Regular rate and rhythm.

Respiratory:  Respirations: Tachypneic, Breath sounds: Rhonchi present. 

Gastrointestinal:  Nontender.

Back:  Normal range of motion.

Musculoskeletal:  Normal ROM.

Neurological:  Alert and oriented to person, place, time, and situation.

Psychiatric:  Cooperative.

 

Medical Decision Making

Differential Diagnosis:  Pneumonia, congestive heart failure, pulmonary embolism, chronic obstructive pulmonary disease, asthma, pleural effusion. 

Electrocardiogram:  rate 97, normal sinus rhythm, No ST-T changes, The Axis is normal.  , P wave and PR interval Left atrial enlargement. 

 

Impression and Plan

Diagnosis

Community acquired pneumonia

Hypoxia 

Inpatient Sample Chart 2 DS, H&P

  Inpatient sample charts / Sample Inpatient cases / Inpatient DRG coding / DRG coding sample charts

DISCHARGE SUMMARY

Primary Diagnosis

Acute Hypoxemic resp failure- background of asthma

 

Secondary Diagnosis

 h/o MS

 Depression

 Chronic pain

 Asthma

 Migraine HA

 

Pertinent Labs, Imaging and Procedures

 no invasive procedures done

 

 CTA chest 3/15/22

IMPRESSION:

1. No evidence of pulmonary emboli to the segmental pulmonary arteries.

2. Patchy and groundglass opacities throughout the lungs, suggestive of

COVID pneumonia.

3. Hepatic steatosis.

 

Hospital Course

Acute Hypoxemic resp failure- background of asthma, RESOLVED NOW

   covid was negative x 2

   cont br tx, o2 support, wean as able- now on on ra

   on abx - levofloxacin, on  steroids

   Consult ID- rec repeat serology, BC and other labs

   Afebrile

 

 h/o MS

   last steroids were 1 mo ago 

 Depression

   cont home meds

  Hypothyroidism

   cont levothyroxine

  Chronic pain

   resume home meds, avoid opioids if able

  Migraine

   restart Fioricet prn

  PPX - dvt-heparin, gi-none needed

 Condition on Discharge

 Stable

 

Physical Exam on Discharge  

General: conscious, coherent, nad

Eye: anicteric sclerae, pink palpebral conjunctivae

Neck: supple, non-tender

Respiratory: symmetrical chest expansion, ctab

Chest: rrr, no mrg

Gastrointestinal: nabs, Soft, Non-tender

Integumentary: warm, dry, good capillary refill

Extremities: 2+ pulses distally, no c/c/e

Lymphatics: no lymphadenopathy appreciated, neck normal

Neurologic: oriented x 3, no fd's noted, mmt 5/5

Psychiatric: not homicidal, not suicidal

 

Diet

Advance diet as tolerated

 

Activity

 Advance as tolerated

 

Disposition

 Home

 

Pending Labs

 None

 

H&P

 

 

Chief Complaint

Pt arrives from PCP office, reporting worsening cough she has had since Sunday. Pts reports O2 of 85% at PCPs office. Pt reports chest tightness, denies fever. Pt reports diff breathing, denies all other complaints.

 

History of Present Illness

Pt is a 42 y/o female with a h/o ms, chronic pain, and anxiety who came for dyspnea, Symptoms were present for the last 3 days. Other symptoms have been cough, fatigue and chest pain. Workup showed severe pna and resp failure. She was admitted for further care.

 

Review of Systems

All other systems were reviewed and are negative except for what is mentioned in the hpi.

 

Physical Exam

Vitals & Measurements

T: 36.8  °C (Tympanic)  TMIN: 36.2  °C (Tympanic)  TMAX: 36.8  °C (Tympanic)  HR: 92(Peripheral)  HR: 92(Peripheral)  RR: 20  RR: 20  BP: 141/81  SpO2: 92%  SpO2: 92%  HT: 170.000 cm  WT: 113.000 kg  Pain Score: 9  O2 Flow Rate: 6  O2 Therapy: Nasal cannula   

General: conscious, coherent, nad

Eye: anicteric sclerae, pink palpebral conjunctivae

Neck: supple, non-tender

Nose: nc in place

Respiratory: symmetrical chest expansion, bilat crackling noted

Chest: rrr, no mrg

Gastrointestinal: nabs, Soft, Non-tender

Integumentary: warm, dry, good capillary refill

Extremities: 2+ pulses distally, no c/c/e

Lymphatics: no lymphadenopathy appreciated, neck normal

Neurologic: oriented x 3, no fd's noted, mmt 5/5

Psychiatric: not homicidal, not suicidal

 

Assessment/Plan

Acute Hypoxemic resp failure- background of asthma

   covid was negative x 2

   cont br tx, o2 support, wean as able

   on abx - levofloxacin, on iv steroids

  h/o MS

   on fetzima

 Depression

   cont home meds

 Hypothyroidism

   cont levothyroxine

  Chronic pain

   resume home meds, avoid opioids if able

 other chronic conditions to be monitored and tx to be adjusted as needed

 PPX - dvt-heparin, gi-none needed

 

Pt will be admitted to full inpatient status. Given their current diagnosis and medical condition it is reasonable to assume that they will need a minimum of a 2-night hospitalization for further evaluation and treatment of their current medical conditions.

 

Images

 

CTA chest 3/15/22

IMPRESSION:

1. No evidence of pulmonary emboli to the segmental pulmonary arteries.

2. Patchy and groundglass opacities throughout the lungs, suggestive of

COVID pneumonia.

3. Hepatic steatosis.

 

 

Problem List/Past Medical History

Ongoing

Anxiety and depression

Chronic back pain

Colitis

Hyperlipidemia

Hypertension

Migraine

Multiple sclerosis

Osteoarthritis

Historical

No qualifying data

 

Procedure/Surgical History

•Arthroscopy of knee

•Cesarean section

•FESS - Functional endoscopic sinus surgery

•Hysterectomy

 

Medications

Inpatient

albuterol 2.5mg/3mL inhalation solution, 2.5 mg= 3 mL, NEB, q2hr, PRN

clonazePAM, 0.5 mg= 1 tab(s), Oral, BID, PRN

DuoNeb, 3 mL, NEB, BID

levoFLOXacin, 750 mg= 150 mL, IV Piggyback, Q24hr

magnesium oxide, 400 mg= 1 tab(s), Oral, As Directed, PRN

Magnesium Sulfate 50% additive + D5W 200 mL

methylPREDNISolone IV, 80 mg= 2 vial(s), IV Push, q6hr

Normal Saline 1,000 mL, 1000 mL, IV

Normal Saline Flush, 10 mL, IV Push, As Directed, PRN

ondansetron, 4 mg= 2 mL, IV Push, q6hr, PRN

oxyCODONE immediate release, 5 mg, Oral, q6hr, PRN

potassium chloride, 20 mEq= 1 tab(s), Oral, As Directed, PRN

Tylenol, 650 mg= 2 tab(s), Oral, q6hr, PRN

 

Home

amitriptyline 100 mg oral tablet, 200 mg= 2 tab(s), Oral, Once a day (at bedtime)

baclofen 20 mg oral tablet, 20 mg= 1 tab(s), Oral, TID

benzonatate 100 mg oral capsule, 100 mg= 1 cap(s), Oral, BID

busPIRone 15 mg oral tablet, 15 mg= 1 tab(s), Oral, BID

diazePAM, 5 mg, Oral, TID

divalproex sodium 250 mg oral tablet, extended release, 750 mg= 3 tab(s), Oral, Once a day (at bedtime)

Fetzima 120 mg oral capsule, extended release, 120 mg= 1 cap(s), Oral, HS

gabapentin 600 mg oral tablet, 600 mg= 1 tab(s), Oral, QID

hydroCHLOROthiazide 25 mg oral tablet, 25 mg= 1 tab(s), Oral, HS

hydrOXYzine hydrochloride 50 mg oral tablet, 50 mg= 1 tab(s), Oral, TID, PRN

levothyroxine, 175 mcg, Oral, Daily

meloxicam 15 mg oral tablet, 15 mg= 1 tab(s), Oral, HS

pravastatin 20 mg oral tablet, 20 mg= 1 tab(s), Oral, Once a day (at bedtime)

ProAir HFA 90 mcg/inh inhalation aerosol, 2 puff(s), INH, q4hr, PRN

ramelteon 8 mg oral tablet, 8 mg= 1 tab(s), Oral, Once a day (at bedtime)

Singulair 10 mg oral tablet, 10 mg= 1 tab(s), Oral, qPM

tiZANidine 4 mg oral capsule, 4 mg= 1 cap(s), Oral, TID

 

Allergies

Keflex (Hives)

azithromycin (Hives)

penicillins (Hives)

Social History

Alcohol - Denies Alcohol Use

Electronic Cigarette/Vaping - Denies Electronic Cigarette Use

Electronic Cigarette Use: Never.

Substance Abuse - Denies Substance Abuse Never

Tobacco - High Risk

10 or more cigarettes (1/2 pack or more)/day in last 30 days Tobacco Use:. 3/4 pack per day. 15 year(s).

 

Family History

Deceased Family Member(s):

Inpatient Sample Chart 2 Progress Notes

 Inpatient sample charts / Sample Inpatient cases / Inpatient DRG coding / DRG coding sample charts

PROGRESS NOTES

03/17

Subjective

afeb, no chillsor sweats

breathing better. on RA, sats ok

walking some

less wheezing and cough, still non productive

no nv/d/

no rash, itch

 

Health Status

Allergies: 

Allergic Reactions (Selected)

Moderate

Azithromycin- Hives.

Keflex- Hives.

Penicillins- Hives., 

Allergies (3) Active           Severity                               Reaction                                                             

penicillins            Moderate                           Hives 

Keflex   Moderate                           Hives 

azithromycin      Moderate                           Hives 

 

Problem list: 

All Problems

Anxiety and depression

Chronic back pain

Colitis

Hyperlipidemia

Hypertension

Migraine

Multiple sclerosis

Osteoarthritis

 

Allergies (3) Active           Severity                               Reaction                                                             

penicillins            Moderate                           Hives 

Keflex   Moderate                           Hives 

azithromycin      Moderate                           Hives 

 

 

Objective

 

Vital Signs (last 24 hrs)_____      Last Charted___________

Temp Tympanic                                                36.6 DegC 

Heart Rate Peripheral                                     97 bpm 

Resp Rate                                                            18 br/min

SBP                                                                        H 149 mmHg

DBP                                                                        84 mmHg

 

General:  No acute distress  looks better

Mouth: no lesions, no thrush

Eye:  conjunctiva and sclera nl

Neck:  Supple. 

Respiratory:  Lungs clear bilaterally, no wheezes

Cardiovascular:  Regular rhythm, No murmur. 

Gastrointestinal:  Soft, Non-tender, Normal bowel sounds. 

Integumentary:  Warm, Dry, No rashes/lesions

Extremities: No peripheral edema noted

Neurologic:  Alert, No focal deficits noted

Psychiatric:  Cooperative.   

PICC;

Foley:

PIV:

 

Labs:

IgG level 1041

repeat blood cultures neg thus far

urine strep Ab pending

toxoplasma Ab pending

   

Impression and Plan

Community acquired pneumonia

   atypical organisms suspected given symptoms and CTA appearance

       RVP neg x 2

       BNP low

       PCT not elevated

bacteremia

      suspect contaminants: drawn at same site LAC. No indwelling or artificial devices

MS, not on immunosuppressants currently

hx pneumonia and sinusitis, consider CVID

     but IgG level is normal

 

 

REC:   D/W Dr XXX

           agree with change to po levoflox

           ok to discharge tomorrow if stable.

           plan 10 days total treatment with levoflox

 

03/16

Subjective

Asked to see for pneumonia

Pt reports rather sudden onset of SOA, cough, chest pressure 3 days ago. She has an underlying hx of asthma and uses and inhaler regularly along with prn nebulizer. She utilized those to the max allowed and sx nevertheless progressed. She went to her PCP office yesterday, 02 sats 85%. She was admitted. CXR with diffuse infiltrates, CTA chest with diffuse GGO, no thrombus. She has not been febrile, denies chills sweats. No HA, sore throat, swollen glands, GI upset, abd pain, diarrhea, blood in stool or urine, no dysuria, myalgias, rash, itch. Cough is dry, no hemoptysis, no chest pain.

RVP neg x 2

Has hx of pneumonia x 2, has received two pneumonia vaccine doses. Hx sinusitis, s/p surgery.

PMHx: MS, on a Q6month infusion, which was delayed by Covid, therefore no infusion for 9 months.

          chronic asthma

SHx: lives with husband, he has not been ill. One dog and 9 cats in the household. She smokes cigarettes, denies vaping.

FHx non contrib for infection problems

ROS: as above. 

 

Health Status

Allergies: 

Allergic Reactions (Selected)

Moderate

Azithromycin- Hives.

Keflex- Hives.

Penicillins- Hives., 

Allergies (3) Active           Severity                               Reaction                                                             

penicillins            Moderate                           Hives 

Keflex   Moderate                           Hives 

azithromycin      Moderate                           Hives 

 

Current medications:  (Selected)

Problem list: 

All Problems

Anxiety and depression

Chronic back pain

Colitis

Hyperlipidemia

Hypertension

Migraine

Multiple sclerosis

Osteoarthritis

 

Allergies (3) Active           Severity                               Reaction                                                             

penicillins            Moderate                           Hives 

Keflex   Moderate                           Hives 

azithromycin      Moderate                           Hives 

   

Objective

Vital Signs (last 24 hrs)_____      Last Charted___________

Temp Tympanic                                                L 36.5 DegC 

Heart Rate Peripheral                                     95 bpm 

Resp Rate                                                            18 br/min

SBP                                                                        138 mmHg 

DBP                                                                        81 mmHg 

 

General:  No acute distress   alert, responsive

Mouth: no lesions, no thrush

Eye:  conjunctiva and sclera nl

Neck:  Supple. no nodes, thyroid normal 

Respiratory:  BS decreased bilat, with diffuse exp wheezes

Cardiovascular:  Regular rhythm, No murmur. 

Gastrointestinal:  Soft, Non-tender, Normal bowel sounds. 

Integumentary:  Warm, Dry, No rashes/lesions

Extremities: No peripheral edema noted

Neurologic:  Alert, No focal deficits noted

Psychiatric:  Cooperative.  

PICC;

Foley:

PIV:

 

Results Review

Impression and Plan

Community acquired pneumonia

   atypical organisms suspected given symptoms and CTA appearance

       RVP neg x 2

       BNP low

       PCT not elevated

bacteremia

      suspect contaminants: drawn at same site LAC. No indwelling or artificial devices

MS, not on immunosuppressants currently

hx pneumonia and sinusitis, consider CVID

 

REC: Agree with levoflox for empiric coverage.

         Check serum IgG

         urine strep pneumo antigen pending

          Will add additional serologies.

         repeat blood cultures

 

 

 

03/16

A/P

Acute Hypoxemic resp failure- background of asthma

   covid was negative x 2

   cont br tx, o2 support, wean as able

   on abx - levofloxacin, on iv steroids

 

 h/o MS

   last steroids were 1 mo ago

 

 Depression

   cont home meds

 

 Hypothyroidism

   cont levothyroxine

 

 Chronic pain

   resume home meds, avoid opioids if able

 

 other chronic conditions to be monitored and tx to be adjusted as needed

 

 PPX - dvt-heparin, gi-none needed

 

 Cont current care. Wean down o2 as able. She is still requiring a high amount of o2.

d/w family and pt at bedside - pt husband

 

Pt with no acute issues overnight. Feeling better.

 

  Temperature        36  

 Systolic Blood Pressure        124

 Diastolic Blood Pressure        67

 Pulse        88   

 SpO2        92  

 Respiratory Rate        20

 

  

General: conscious, coherent, nad

Eye: anicteric sclerae, pink palpebral conjunctivae

Neck: supple, non-tender

Nose: nc in place

Respiratory: symmetrical chest expansion, bilat crackling noted

Chest: rrr, no mrg

Gastrointestinal: nabs, Soft, Non-tender

Integumentary: warm, dry, good capillary refill

Extremities: 2+ pulses distally, no c/c/e

Lymphatics: no lymphadenopathy appreciated, neck normal

Neurologic: oriented x 3, no fd's noted, mmt 5/5

Psychiatric: not homicidal, not suicidal

 

Medications (24) Active

 Scheduled: (13)

albuterol-ipratropium Inh Sol 3 mL   NEB, BID

amitriptyline 25 mg Tab   8 tab(s), Oral, Once a day (at bedtime)

atorvastatin 20 mg Tab 1 tab(s), Oral, Once a day (at bedtime)

baclofen 10 mg Tab 2 tab(s), Oral, TID

busPIRone 10 mg Tab UD 1.5 tab(s), Oral, BID

diazepam 5 mg Tab 1 tab(s), Oral, TID

divalproex sodium 250 mg Tab ER(mg 3 tab(s), Oral, Once a day (at bedtime)

gabapentin 300 mg Cap mg 2 cap(s), Oral, QID

heparin 5000 units/mL Soln Subcutaneous, q8hr

levofloxacin  750 mg 150 mL, IV Piggyback, Q24hr

levothyroxine 100 mcg (0.1 mg) + levothyroxine 75 mcg (0.075 mg) Tab [mcg, Oral, Daily

methylPREDNISolone Sod Succ 40 mg Inj 2 vial(s), IV Push, q6hr

montelukast 10 mg Tab 1 tab(s), Oral, qPM

 Continuous: (1)

Sodium Chloride 0.9% 1,000 mL  1,000 mL, IV, 100 mL/hr

 PRN: (10)

acetaminophen 325 mg Tab mg 2 tab(s), Oral, q6hr

albuterol 2.5 mg/3 mL (0.083%) Sol UDmg 3 mL, NEB, q2hr

benzonatate 100 mg Cap mg 1 cap(s), Oral, BID

hydrOXYzine pamoate 25 mg Cap  cap(s), Oral, TID

magnesium oxide 400 mg Tab Oral, As Directed

magnesium sulfate 50% 2mL + Dextrose 5% in Water 100 mL 200 mL  2 gm 4 mL, IV Piggyback, As Directed

ondansetron 4 mg/2mL Inj Sol, IV Push, q6hr

oxycodone 5 mg Tab  1 tab(s), Oral, q6hr

potassium chloride 20 mEq ER Tab  1 tab(s), Oral, As Directed

Sodium Chloride 0.9% Inj Sol 10 mL flush , IV Push, UD

 

New Images

All images from this admission have been reviewed

 

no new images yet today

 

03/17

Subjective

Pt has migraine today, Up in room, ok to bathroom.

Review of Systems

Constitutional: [No fevers, chills, sweats]

 Respiratory: [+ shortness of breath, cough]

 Cardiovascular: [No Chest pain, palpitations, syncope]

 Gastrointestinal: [No nausea, vomiting, diarrhea]

 Genitourinary: [No hematuria]

 Peripheral- no claudication, no cramping

 

Objective

Vitals & Measurements

T: 36.7  °C (Tympanic)  TMIN: 36.0  °C (Tympanic)  TMAX: 37.0  °C (Tympanic)  HR: 103(Peripheral)  HR: 104(Peripheral)  RR: 20  RR: 20  BP: 147/82  SpO2: 96%  O2 Flow Rate: 4  O2 Therapy: Hi-flow nasal cannula  O2 Therapy: Hi-flow nasal cannula

 

Physical Exam

General: [Alert and oriented, well nourished, no acute distress].

 Neck: [Supple, non-tender, no carotid bruits, no JVD, no lymphadenopathy].

 Lungs: [Clear to auscultation and percussion, non-labored respiration].

 Heart: [Normal rate, regular rhythm, no murmur, gallop or edema].

 Abdomen: [Soft, non-tender, non-distended, normal bowel sounds, no masses].

 Musculoskeletal: [Normal range of motion and strength, no tenderness or swelling].

 Skin: [Skin is warm, dry and pink, no rashes or lesions].

 Neurologic: [Awake, alert and oriented X4, CN II-XII intact].

 Peripheral: No edema

 

Diagnostic Results

3/15 CT angio

1. No evidence of pulmonary emboli to the segmental pulmonary arteries.

2. Patchy and groundglass opacities throughout the lungs, suggestive of

COVID pneumonia.

3. Hepatic steatosis.

 

 3/15 CXR

Findings concerning for multifocal pneumonia. Recommend continued

follow up.

 

Assessment/Plan

42 y/o female

Acute Hypoxemic resp failure- background of asthma

   covid was negative x 2

   cont br tx, o2 support, wean as able- now on 2.5L

   on abx - levofloxacin, on iv steroids

   Consult ID- rec repeat serology, BC and other labs

   Afebrile

 

 h/o MS

   last steroids were 1 mo ago

 

 Depression

   cont home meds

 

 Hypothyroidism

   cont levothyroxine

 Chronic pain

   resume home meds, avoid opioids if able

 Migraine

   restart Fioricet prn

 PPX - dvt-heparin, gi-none needed

Cont current care. Wean down o2 as able. She is still requiring a high amount of o2.