medical coding home work

timer Asked: Apr 14th, 2015

Question description

From the health record of a patient seen in the emergency room/observation area for an allergic reaction:

Discharge Summary

Date of Discharge: 01/08/XX

Chief Complaint: Allergic reaction to Bactrim, resulting in angioedema and mild respiratory distress.

Hospital Course: Fifty-six-year-old male admitted for angioedema after taking Bactrim for an ear infection. The patient had mild respiratory distress and marked swelling of his hands, face, and his oropharynx. The patient was given IV steroids in the Emergency Room and was admitted overnight for observation. The patient's swelling rapidly improved and by the morning after his admission he was back to baseline. He had no complaints of shortness of breath and desired to go home.

Condition on Discharge: Good. Activity: As tolerated. Diet: As tolerated.

Medications: Home medications only including:

1. Celebrex 200 mg one b.i.d.

2. Isosorbide 30 mg once a day.

3. Atenolol 25 mg per day.

4. Lipitor 10 mg per day.

Follow-Up: Will be as needed with primary care physician if ear problem returns and/or respiratory distress.

Emergency Assessment

Chief Complaint: Swelling, itching, and change in voice.

Present Illness:  This is a 56-year-old white male with a history of allergic reaction to an antibiotic in the past, who presents today after taking his second dose of Bactrim this morning at home. He then had acute onset of swelling, redness, itching, and change in voice; also states that he was slightly short of breath but no wheezing. He denies any nausea, vomiting, fevers, chills.

Past Medical History: Coronary arter disease, MI 2 years ago, is currently take Celebrex, Isosorbide, Atenolol, Lipitor, and Bactrim that he just started on his morning.

Physical Examination:  Appears very red, swollen diffusely with erythematous rash, macular type rash. Blood pressure is 145/77, heart rate of 120, respiration rate 18 and 02; saturation is 96%. On room air. HEENT: He does have swollen eyelids, both upper and lower eyelids, with also some facial swelling and some uvular swelling as well as some lateral pharyngeal and uvualr swelling, which appears to be allergic in nature. His tongue appears also slightly swollen, does not have any neck swelling, also has an erythematous rash. Lungs: Clear to auscultation with no wheezing noted. Abdomen: Soft, nontender.

Ed Course: Received Benadryl 25 mg IV, Pepcid 20 mg IV, Solu-Medrol 125 mg IV. At this point, his voice was still changing, and decision was made to admit the patient to the hospital for observation and then to observe and given a second dose of Solu-Medrol and Benadryl. Consultation between patient's private physician.

Select the correct codes for this observation patient.

a. 961.0, 786.09, 995.1, 693.0, E857, E849.0

b. 995.20, E931.0, E849.0

c. 995.1, 786.09, E931.0, E849.0

d. 995.1, 786.09, 693.0, E930.9, E849.0

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