Question

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Documentation Support for Principal Diagnosis You are the coding superviso at Vale Community General Hospital. An HIM student, Rachel, is working with you taday. She is looking at some charts and has asked you how you determine if the documentation supports the codes. You decide to walk through the charts with her and explain each one. The principal diagnoses are shown in Table 5 3. This table is also available on the student cempanion website for your use What would you tell Rachel about each? Include the symptoms, method of diagnosis, treatment, etc. that she should look for. TABLE 5-3 Principal Diagnosis and Explanation Principal Diagnosis and Explanation Principal Diagnosis: Pneumonia Explanation: Principal Diagnosis: Septicemia Explanation Principal Diagnosis: Respiratory failure Explanation: Principal Diagnosis: Congestive heart failure Explanation: Principal Diagnosis: Explanation: Acute cholecystitis with cholelithiasis Principal Diagnosis: Preeclampsia Explanation Principal Diagnosis: Thrombophlebitis Explanation: Principal Diagnosis: Cerebrovascular accident ICVAI Explanation: Principal Diagnosis: Hiatal hernia Explanation Principal Diagnosis: Gastroenteritis Explanation

Answer 1

Pneumonia:
• Definition: Pneumonia is an infection of the lungs.
• Symptoms: cough, rusty, green sputum, fever, fast breathing, shaking chills, shortness of breath, chest pain, fast heartbeat, fatigue, nausea, vomiting, diarrhoea, sweating, headache, confusion, cyanosis.
• Diagnostic tests: History and physical examination, chest x-ray, CT scan, blood test for WBC, blood culture, ABG, sputum analysis, bronchoscopy
• Treatment: Antibiotics, antiviral medication, antifungal.
Septicemia:
• Definition: It is a serious blood stream infection.
• Symptoms: Chills, elevated body temperature, very fast respiration, rapid heart rate, confusion, nausea, vomiting, decreased urine output, shock.
• Diagnostic tests: signs of infection, ABG, blood counts, blood culture.
• Treatment: Broad spectrum antibiotics, fluid replacement.
Respiratory failure:
• Definition: It is a syndrome where the respiratory system fails in one or both of it’s gas exchange function.
• Symptoms: hypoxemia, hypercapnia, cyanosis, dyspnea, confusion, pulmonary hypertension.
• Diagnostic tests: chest x-ray, echocardiography, pulmonary function test, electrocardiography, ABG, complete blood count.
• Treatment: Ventilator, extracoeporeal membrane oxygenation, diuretics, nitrates, opioid Analgesics, inotropic agents, anticholinergics, corticosteroids.
Congestive heart failure:
• Definition: It is a chronic progressive condition that affects the pumping of heart muscles.
• Symptoms: Fatigue, chest pain, swelling in ankles, feet and legs, rapid breathing, wheezing, cyanosis, irregular heart beat.
• Diagnostic tests: electrocardiogram, MRI, stress test, blood test, cardiac catheterization.
• Treatment: ACE inhibitors, beta blockers, diuretics, angioplasty.