This is a 19-year-old with a living-related donor kidney transplant
as of last month and admitted to hospital for possible
sepsis.
HISTORY: This patient has type 1 diabetes and had been on dialysis
for a number of years before transplantation. She received her
mother’s kidney on the 14th of last month from the Medical Center
Transplant Program in Dallas. She was there this Tuesday for a
transplant visit and apparently did not feel well, but they were
not certain whether this was a problem or not; but they did go
ahead and do blood cultures and called the public health nurse, who
was visiting the patient today, and said that one of the cultures
was positive for group B strep. The home health nurse called me and
stated that the patient has really gone downhill the past few days
and was quite fatigued with generalized malaise. Denied cough,
fever, or shaking chills but looked poor overall, and the nurse was
quite concerned. We recommended she be brought here for evaluation
and treatment as an emergency. After arrival here, she was in no
acute distress. Initially, she had bibasilar crackles on deep
breathing; however, most of these cleared. I cannot hear any
significant pulmonary abnormality on auscultation or percussion.
Her heart is normal regular rhythm. No significant murmurs, rubs,
S3, or S4. Her
abdomen is negative. Her left lower-quadrant kidney is nontender.
She has no edema and no lateralizing neural sounds. She is a little
lethargic. She does not feel warm. Apparently she is afebrile. Her
blood pressure is normal, and she is not tachycardic, but she
simply does not look well. Past history, social history, and system
review are per our recent old chart and noncontributory at
present.
MEDICATIONS: See med sheet.
CLINICAL IMPRESSION: One positive group B strep blood culture,
significance, and/or etiology to be determined. My impression at
this time is probably a significant finding, and I suspect that
this will become a progressive syndrome if not treated. ADDITIONAL
DIAGNOSES: 1. Living-related donor kidney transplant 2. Diabetes
mellitus type 1 3. Hypertension PLAN: Repeat culture. Culture
urine. Do chest x-ray stat and repeat lab. Will empirically treat
pending results at this time,
In Appendix A of this workbook you will find a section titled Reports, which contains originals reports. Read the reports indicated below and supply the appropriate CPT and ICD-10-CM codes.
CPT code is current procedural terminology codes used by healthcare provides and insurance companies for coding medical , surgical procedures .
CPT code for blood culture is 87040
CPR code for urine culture is 87086
ICD -10 CM is International Classification of Disease ,10th version ,Clinical Modification. This code is used by physicians ,other health care workers and insurance companies to clarify disease, symptoms in the form of codes.
ICD code for Living related donor kidney transplant is Z94.0
ICD code for Hypertension is I10
ICD code for Diabetes Mellitus is E10.65
This is a 19-year-old with a living-related donor kidney transplant as of last month and admitted...
This is a 19-year-old with a living-related donor kidney transplant as of last month and admitted to hospital for possible sepsis.HISTORY: This patient has type 1 diabetes and had been on dialysis for a number of years before transplantation. She received her mother’s kidney on the 14th of last month from the Medical Center Transplant Program in Dallas. She was there this Tuesday for a transplant visit and apparently did not feel well, but they were not certain whether this...
Frances Jenkins, 63 year old female with a 15 year diagnosis of Diabetes, presents in the clinic. She also has a 10 year history of hypertension. Her diabetes and hypertension has been only moderately controlled. Today she reports edema in her hands, face, and feet. She reports that she is tired and "just doesn't seem to have any energy". Her blood sugar is within acceptable limits. Her urine is positive for blood and protein. What complication of diabetes might you...
Mr. Scott is a 31-year-old male with past medical history of a congenital anomaly that has led to kidney disease. The nephrologist has mentioned it is time to pursue either dialysis or a donor kidney. Mr. Scott and his family elect to proceed with a kidney transplant. He receives a kidney transplant from a living donor relative. Describe the nursing priorities and interventions when providing care to the renal transplant patient in the immediate post-op periods. (Choose at least 4...
The patient is a 48-year-old unconscious woman admitted to the ED. She has a known history of type 1 diabetes mellitus. Her daughter accompanies her and tells the staff that her mother has had the “flu” and has been unable to eat or drink very much. The daughter is uncertain whether her mother has taken her insulin in the past 24 hours. The patient’s vital signs are temperature 101.8° F; pulse 120, weak and irregular; respiration 22, deep, and fruity...
The patient is a 48-year-old unconscious woman admitted to the ED. She has a known history of type 1 diabetes mellitus. Her daughter accompanies her and tells the staff that her mother has had the “flu” and has been unable to eat or drink very much. The daughter is uncertain whether her mother has taken her insulin in the past 24 hours. The patient’s vital signs are temperature 101.8° F; pulse 120, weak and irregular; respiration 22, deep, and fruity...
5. A 38 year old kidney transplant recipient is prescribed immunosuppressant therapy with IV cyclosporine (Sandimmune), prednisone, and ketoconazole. Answer all questions and include a detailed rationale for your answer. a. The client asks why she is prescribed ketoconazole in addition to cyclosporine. What should the nurse explain is the main reason these two drugs are administered concurrently? b. It is important for the nurse to teach the client about cyclosporine's possible effects on a developing fetus and that current...
A 44-year-old Caucasian woman is admitted for local wide excision of a large mole that has been diagnosed as malignant melanoma on her upper thigh. Her past history is negative for serious illness. She was hospitalized for the birth of her three children. She admits to being an avid sun worshipper" and is noted to have very dark brown skin and some premature aging of the facial skin. 1. Considering the possible etiology of melanoma, what effect does the exposure...
A 44-year-old Caucasian woman is admitted for local wide excision of a large mole that has been diagnosed as malignant melanoma on her upper thigh. Her past history is negative for serious illness. She was hospitalized for the birth of her three children. She admits to being an avid sun worshipper" and is noted to have very dark brown skin and some premature aging of the facial skin. 1. Considering the possible etiology of melanoma, what effect does the exposure...
This is a 33-year-old female, primigravida, who came in experiencing early labor. Patient is at 40 weeks gestation. The patient had been scheduled for a cesarean section due to breech presentation. This patient has had no significant problems during first, second, or third trimester. The patient’s past medical history is noncontributory. The patient’s LMP was 06/22/2017, placing her EDC at 04/05/2018. Ultrasounds were performed throughout the pregnancy and revealed adequate growth during the pregnancy and EDC remained technically the same....
Background Information: Alison is a 12 month old who has been vomiting for the past 12 hours. Since waking at 6 AM she has "not held anything down." It is now 5:30 PM and Alison's mother is becoming concerned. She calls the primary care office and the nurse recommends that Alison be brought into the office for evaluation. On initial assessment, Alison is lethargic and very quiet. Her lips and skin are dry. She is crying at times, but does...