Case Study 1: Patient Admission Concepts related to HLTEN512B Topic 1 Mrs. Gwen Jones is a 70 year old woman who has been admitted to your ward after arriving from her doctor’s surgery. Her GP has included a letter stating that he has assessed Mrs. Jones and requests she is admitted. She is feeling very unwell, with a high temperature, frequency of urination and burning when urinating. She appears slightly confused. She complains of back pain.
It is very important to get the history to figure out what may be causing these symptoms. The best code for this scenario is 99205. • A 30-year-old patient presents complaining of flu-like symptoms characterized by unremitting cough, sinus pain, and thick nasal discharge. An examination reveals bronchitis and sinus infection. The patient is prescribed a 5-day course of Zithromax.
Tori Rivers is a ten-year-old female, admitted for severe right lower quadrant pain and fever. A CT scan confirmed appendicitis. She is one day post-op. She is allowed out of bed to the chair. When getting out of bed, she walks bent over holding her incision and grits her teeth as she sits down.
Scenario The wife of C.W., a 70-year-old man, brought him to the emergency department (ED) at 0430 this morning. She told the ED triage nurse that he had had dysentery for the past 3 days and last night he had a lot of “dark red” diarrhea. When he became very dizzy, disoriented, and weak this morning, she decided to bring him to the hospital. C.W.’s vital signs (VS) were 70/- (systolic blood pressure [BP] 70 mm Hg, diastolic BP inaudible), 110, 20. A 16-gauge IV catheter was inserted, and a lactated Ringer’s (LR) infusion was started.
Within 30 minutes of presenting in the ED, Dr. Westwood developed bradycardia with a BP of 90/50 mmHg. Atropine was administered in response to the bradycardia. Intravenous hydration, gastric lavage, and activated charcoal followed a presumptive diagnosis of tetrodotoxin poisoning that was based on the clinical presentation in the ED. Five hours after treatment, the following vital signs were noted: • BP 125/79 mmHg • HR 78 bpm • Oxygen saturation: 97% on room air After discussing his case with his physician, he learned that he had probably been the victim of puffer fish poisoning. The active toxin in the tissues of this fish is a chemical called tetrodotoxin (TTX).
Mrs. Anderson is asymptomatic when she is allowed to drink massive volumes of water. She has been recently moved to a supervised care facility where her water intake has been drastically limited. Upon physical exam Mrs. Anderson’s skin is wrinkled, shows dry mucous membranes, disorientation, lethargy and confusion. Mrs. Anderson’s vital signs included a blood pressure of 70/55, heart rate of 124 beats per minute. Her blood plasma osmolality is 380mOsm/kg, sodium of 152 mEq/L, BUN of 36mg/dL, creatinine of 2.1mg/dL and a lithium level of 1.9mEq/L.
Mr. R described his chest pain as tightness in his chest and rated pain 8/10 he was given 300mcg of anginine and 300mg of aspirin, oxygen was applied, the pain was relieved slightly, rating the pain 6/10 then 1/10 enroute to hospital. On arrival to Hornsby Hospital at 1410hrs, Mr. R was hypotensive 80 systolic, he was given a 250ml bolus of normal saline, an ECG was recorded which showed Mr. R was infracting, Clopidogrel 300mg per oral was given and Heparin 5000unit via intravenous infusion was commenced, urgent transport was organized, at 1440hrs Mr. R was transport to Royal North Shore Hospital emergency
Points Awarded 24.00 Points Missed 2.00 Percentage 92.3% Diagnosis Shiri's husband, Alum, notices that her left eyelid is drooping and she tells him she is experiencing double vision. After another choking episode, Alum brings his wife back to the healthcare provider who now thinks she may have myasthenia gravis. Her healthcare provider administers a Tensilon (edrophonium chloride) test to help confirm the diagnosis of myasthenia gravis (MG). 1. Which response to the test indicates that Shiri has myasthenia gravis?
Errors and Compliance in Coding The cost of health care is sky rocketing over the recent years. One of the reasons for this is because of medical billing errors. One-third of medical billings have errors in them. (National Public Radio, 2006) This is why it is important for patients to look over their bills very closely and not hesitate to ask questions to the health care facility and your insurance provider. These errors are not always easily discovered.
Acute Health Assessment Task 1 Case Study Mrs Jones is a 78-year-old lady, who has arrived via the emergency department after falling at home and fracturing her hip. She is scheduled for surgery in the morning. Pathology indicated that her haemoglobin level was 9.7g/dL, and she has been prescribed a transfusion of 2 units of packed red blood cells (PRBC). Transfusion Rationale: Haemoglobin is the protein molecule in red blood cells that carries oxygen from the lungs to the body’s tissues and returns carbon dioxide from the tissues to the lungs. Levels which are considered to be within normal limits for a female are between 11.5 to 16.5g/dL.