ADMISSION DATE: 04/26/YYYY DISCHARGE DATE: 04/30/YYYY ADMISSION DIAGNOSIS: Fever of undetermined origin. DISCHARGE DIAGNOSIS: Acute pyelonephritis. SUMMARY: This 30 year old white female had high fever off and on for several days prior to admission without any localizing signs or symptoms. Preliminary studies done as an outpatient were unremarkable except to indicate an infection some place. She was ultimately seen in the office, temperature was 103 to 104. She was becoming dehydrated, washed out, weak, tired, and she was admitted for further workup and evaluation. Workup included a chest x-ray that was normal. Intravenous pyelogram was normal. Blood culture report is normal. Urine culture grew out Escherichia coli greater than 100,000 colonies. Throat culture was normal. One blood culture did finally grow out an alpha strep viridans. I talked to Dr. Burke about this and we decided on the basis of her clinical condition and the fact that this did not grow on all bottles it was more likely a contaminate. Urine showed a specific gravity of 1.010, albumin 1+, sugar and acetone were negative, white blood cells 6 to 8, red blood cells 1 to 2. White count 13,100, Hemoglobin 12, hematocrit 35.1, segmental cells 81, lymphocytes 11, monocytes 5, eosinophils 1, bands 2. Mononucleosis test was negative. Alkaline phosphatase 127, blood sugar 125, sodium 142, potassium 4.7, carbon dioxide 30, chloride 104, cholesterol 119, Serum glutamic oxaloacetic transaminase 41, lactate dehydrogenase 151, creatinine 0.9, calcium 9.8, phosphorus 3.3, bilirubin 0.6, total protein 6.8, albumin 4.0, uric acid 6.5. Electrocardiogram was reported as normal. She was started on intravenous fluids, intravenous Keflex, her temperature remained elevated for approximately 48 hours and now has been normal for the last 48 to 72 hours. She feels better, hydration is better, eating better, no urinary symptoms. She’s being discharged at this time on Keflex 500 four times per day, increased fluid intake. To be seen in follow up in the office in 1 week. DD: 04/30/YYYY Reviewed and Approved: John Black MD ATP-B-S:02:1001261385: John Black MD (Signed: 5/1/YYYY 2:24:44 PM EST) DT: 05/01/YYYY Physician Authentication GLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 LONG, BETH IPCase001 Dr. BLACK Admission: 04/26/YYYY DOB: 12/17/YYYY ROOM: 369 ADMISSION DIAGNOSIS: Fever undetermined etiology, pyelonephritis, and urinary tract infection. CHIEF COMPLAINT: Chills and fever, just feels lousy for the last 5 days. HISTORY OF PRESENT ILLNESS: The patient began to run a temperature on Sunday, had no other complaints whatsoever. She has not felt like eating for the past 5 days and only taking in fluids and Aspirin. She was seen in the office on 4/24 with 98 temperature but she had just taken Aspirin. At that time physical exam was negative but she had an 18,300 white count. The white count was repeated the next day and found to be 13,400 with temperature elevated at 102-103 unless she was taking Aspirin. She was seen in the office again today, continues to feel lousy and now she has some pain in the left upper flank area posteriorly, she is being admitted to the hospital for a workup with a temperature of 103. FAMILY HISTORY: Negative for cancer, tuberculosis, diabetes, she has a brother with mild epilepsy. She has only been admitted for delivery of her 2 children, otherwise she has always been in excellent health without any problems. She smokes 15-20 cigarettes a day and has done so for the last 15 years. She doesn’t drink. She uses no other drugs. SOCIAL HISTORY: She lives at home with her husband and 2 children. There are no apparent problems. REVIEW OF SYSTEMS: Normal except for the history of the present problem. PAST MEDICAL HISTORY: Non contributory. GENERAL: Shows a cooperative young lady. She shows no pain. She is 30 years old. WEIGHT: 113 lb. TEMPERATURE: 103 oral PULSE: 102 RESPIRATIONS: 18 SKIN: Pink, warm, dry, no evidence of rash or jaundice. HEENT: Head symmetrical. No masses or abnormalities. Eyes react to light and accommodation. Extraocular movements are normal. Sclera is clear. Ears, tympanic membranes are not injected. Mouth and throat are negative. NECK: Supple. No lymph notes felt. No thyromegaly. CHEST: Clear to percussion and auscultation. HEART: Normal sinus rhythm. Not enlarged. ABDOMEN: Soft. She is tender under the left costal margin with no enlargement of any organs. She has pain to percussion in left upper flank area. PELVIC & RECTAL: Deferred. EXTREMITIES: Normal. Peripheral pulses are normal. Given that the principal diagnosis is listed for question #1, please list all secondary diagnoses and the pathways. Please list all appropriate codes and give the proper sequence of the codes listed. Please provide a screenshot of encoder usage for your answer. THE PRIMARY DIAGNOSIS IS Acute pyelonephritis. IS THERE A SECONDARY DIAGNOSIS?
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