QUESTION 8

  1. History of Present Illness
    A 50-year-old disabled male is a resident of a nursing home who has been admitted because of marked congestion and respiratory distress. He is known to have mental retardation and frequent urinary tract and pulmonary infections. He has a recurrent epileptic disorder that is well controlled on Dilantin.

    Physical Examination
    On admission, vital signs include a temperature of 101° F, respiratory rate of 32 breaths per minute, heart rate of 82 beats per minute, and blood pressure of 120/70 mm Hg. Examination of the chest reveals bilateral crepitations. There is moderate redness and edema of the scrotal skin.

    Laboratory Data and Course in Hospital
    His white blood cell count is 8.5; hemoglobin, 12.9 g/dl; polymorphonuclear leukocytes, 64; bands, 19; lymphocytes, 10; monocytes, 6; and eosinophils, 1. A urinalysis shows moderate bacterial and white blood cell count. A urine culture shows mixed flora. The repeat urine culture shows Providencia stuartii sensitive to Fortaz. A sputum culture reveals the presence of methicillin-resistant Staphylococcus aureus, sensitive to vancomycin. A chest X-ray film shows bilateral pulmonary infiltrates. Arterial blood gases on room air show a PO2 of 48, PCO2 of 30, and pH of 7.50. When repeated with the patient on oxygen, PO2 is 66, PCO2 is 36, and pH is 7.45. The patient is treated with intravenous vancomycin and intravenous Fortaz. His pulmonary infiltrate decreases. His oral intake has been somewhat poor, and he has been given intravenous fluids off and on. The nursing staff at the nursing home note that his intake, in terms of eating and taking fluids, is much better. His medications at the nursing home include Dilantin, 200 mg twice a day; Tegretol, 400 mg at 8 a.m. and 4 p.m. and 200 mg at 8 p.m.; and Cipro, 500 mg twice a day; and his maintenance medications are continued. This patient is being discharged today.

    Use Encoder Pro software to assign I-10 code(s) for each of the final diagnosis statements below:

Final Diagnosis

  1. Acute respiratory insufficiency
  2. Bilateral pneumonia due to MRSA
  3. Providencia stuartii (gram-negative bacilli) infection
  4. Mental retardation
  5. Epilepsy
  6. UTI
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