HCS 214 Wk 3 - Respiratory System—Analyzing a Progress Note

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HCS/214 v6

Respiratory System – Analyzing a Progress Note

HCS/214 v6

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Respiratory System – Analyzing a Progress Note

Part 1

Using the following progress note, define the highlighted terms within the chart provided.

This patient returns to the Pulmonary Medicine Clinic for a follow-up evaluation of COPD and emphysema.

Progress Note:

Subjective: The patient is an 85 y.o. female who returns to the clinic for a follow-up evaluation of COPD and emphysema. At the present time, respiratory status is relatively stable. She is still short of breath with activity, but mostly her pulmonary disease has not changed significantly since her last visit. She does have an occasional cough and a small amount of sputum production. No fever or chills. No chest pains.

Objective: Vital signs 99.8 orally, 152/80, pulse 80, respirations 16. Nasal mucosa was mild to moderately erythematous and edematous. Oropharynx was clear. Pulse ox 90% on room air.

Assessment: Chronic obstructive pulmonary disease/emphysema, severe but stable. Mild hypoxemia.

Plan: Portable chest x-ray, complete blood count, arterial blood gases: Start oxygen at 1 Liter, recheck pulse ox after aerosol. Consult a pulmonologist for further orders.

Lisa Jones, PA

*Do not forget to include the sources for your definitions.

40 Points: 1 point for Medical term, 2 points for Definition, and 1 point for Sources

Medical term	Definition	Sources
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Part 2

Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.

30 points: 10 for each correct answer.

Medical term	Medical code
COPD, acute	J44.9 COPD unspecified J44 Other chronic obstructive pulmonary disease J45.901 Asthma, unspecified type, with (acute) exacerbation J44.1 Chronic obstructive pulmonary disease with (acute) exacerbation
Respiratory failure, with hypoxia	J22 Unspecified lower respiratory infection J96.11 Chronic respiratory failure with hypoxia J96.12 Chronic respiratory failure with hypercapnia J96.91 Respiratory failure, unspecified with hypoxia
Emphysema	J98.2 Interstitial emphysema J18.9 Pneumonia, unspecified organism J43.9 Emphysema, unspecified J43.0 MacLeod’s syndrome – Unilateral pulmonary emphysema

References

Centers for Medicare & Medicaid Services (23 Oct. 2015). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.”

HCS 214 Wk 3 - Respiratory System—Analyzing a Progress Note

Respiratory System – Analyzing a Progress Note

Part 1

Medical term

Definition

Sources

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Part 2

References