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CASE STUDY 12: CAROLINA SPENCER PATIENT: Carolina Spencer REASON FOR ENCOUNTER: Assistance with tracheostomy management. HISTORY OF PRESENT ILLNESS: The patient is a 73-year-old female admitted to McGraw Hospital on July 17th with acute ischemic CVA and DKA. The patient has a very compli- cated medical history, including respiratory failure, on prolonged mechanical ventilation. She underwent tracheostomy placement on July 19th and was weaned from mechanical ventilation within 12 hours. She was also diagnosed with hospital-acquired pneumonia, multi-organism, and pulmonary embolism by CTPA. She is currently on heparin drip, while started on Warfarin. She also has end-stage renal disease and is on hemodialysis. PAST MEDICAL HISTORY: In addition to the above, the patient was found to have some type of intracardiac shunt per echocardiogram, not otherwise defined; atherosclerosis of the internal carotid arteries; positive lupus anticoagulants; and long-standing history of diabetes mellitus, type II. SOCIAL HISTORY: Tobacco and alcohol use are unknown. MEDICATIONS: Sliding scale insulin, Reglan, Lantus insulin, diltiazem, Timentin, heparin drip, Warfarin, Bactrim, Pepcid, and iron sulfate. ALLERGIES: No known allergies. REVIEW OF SYSTEMS: Not available. FAMILY HISTORY: Not available. PHYSICAL EXAMINATION: GENERAL: She is an unresponsive female, in no acute distress. VITAL SIGNS: Temperature is 98.6 degrees; respiratory rate is 21 to 25, somewhat irregular; pulse is 102; blood pressure is 122/80; and pulse oximetry is 97% on 50% cuffless tracheostomy. HEENT: Unable to visualize posterior pharynx secondary to the patient's resistance to mouth opening. The patient does have some natural dentition anteriorly. No coating of the tongue is appreciated. The patient has an eschar on the left upper lip, presumably secondary to ET tube. Conjunctivae are clear. Gaze is conjugate. The patient has a size 8 Portex cuffless tracheostomy tube in the midline. CHEST: The patient has a few crackles at the right base, few anterior coarse rhonchi. No wheeze or stridor with the tracheostomy tube, patent. With finger occlusion of the

Answer 1

ICD-10-CM Diagnosis code I67.81 for Acute Cerebrovascular insufficiency.

ICD-10-CM Diagnosis code E10.10 for Type1 diabetes mellitus with Ketoacidosis without coma

ICD-10-CM Diagnosis code J18.9 for Pneumonia,unspecified organism

ICD code 126 is used to code Pulmonary Embolism

ICD-9-CM code 585.6 for End stage Renal disease

ICD-10-PCS code 0B21XFZ for change Tracheostomy Device in Trachea,External Approach

0-Medical and surgical

B- Respiratory system

2-Change

1-Trachea

X- External

F- Tracheostomy

Z-No qualifier

ICD-10-CM Diagnosis code Z43.0 for Encounter for attention to tracheostomy.

I