Discussion Unit 3 Review the SOAP note BELOW. Initial Post Use your lecture materials to determine what ICD-10

Discussion Unit 3

Review the SOAP note BELOW.

Initial Post

• Use your lecture materials to determine what ICD-10 Codes to assign for this patient encounter.
• In paragraph form, construct a discussion that supports the Codes you identified. 
• In the discussion explore how the ICD-10 Codes that you assigned impact third party payor reimbursement for this visit.

Responses need toaddress all components of the question, demonstrate critical thinking andanalysis and include peer-reviewed journal evidence to support the studentsposition.

***SOAP NOTE***

Chief Complaint:

Older sister reports – Our mother died three weeks ago andwe lost our father several months ago.  Ithink that my sister was depressed and just wanted to be with them.

History of PresentIllness:

31-year-old female who was brought to the hospital byambulance.  She was found slumped over inher car in front of the funeral home where memorial services for both herfather and mother had recently been held. On the seat beside her were two empty bottles of sleeping pills, a Bibleopened to Psalm 23, and a note that read:I am going to be with mom and dad.  Itis just too sad being here anymore without them.  I love you all and you will be in my prayers.When she was found by the funeral home director her hair was oily and unkemptand she smelled as if she had not bathed in a long time.  She was wearing a dirty orange T-shirt andjeans.

PMH:

Depression when she was a junior in HS which led topsychiatric admissions at 15 and 19 years of age.  For these admissions she was treated withantidepressants and psychotherapy. Length of stay for both admissions was approximately 5 weeks.  At age 19, following a suicide attempt, shemet her first husband in the psych ward of the hospital. Diagnosed with bipolardisorder 6 years ago.

Information fromSister:

Older sister reports hard life.  Reports both parents were alcoholics.  Parents would go to bars almost every nightand leave the 8 children in the care. The children were eventually removed from the home.  Some of the children went to the Catholicgirls home others were placed in horrible foster homes where they weresubjected to physical and sexual abuse. 

Reports numerous siblings, including the patient, have beenthrough several detoxification centers for alcohol abuse.

Patient is in her second marriage with 3 daughters 2 fromthe first marriage and 1 from the current marriage. 

Reports that after having her third baby the patient wentinto a terrible depression.  Thepatient was under the care of a psychiatrist for this depression and was placedon an anti-depressant after about 3 months of being under the psychiatristscare.  After 3 weeks of being on thisanti-depressant the patient is reported as having gotten really weird;patient was staying up all night pacing around her house and talking to peopleon the phone, she would go on shopping sprees for 2-3 days at a time and max outall her credit cards.  The patientfinally crashed and was taken to the hospital by her family and it was duringthis admission, 6 years ago, that the patient was diagnosed with bipolardisorder.  Sister reports the patient hasbeen on Lithium since being diagnosed with bipolar disorder. 

Reports their father had been sick for a while so his deathwas not unexpected.  However, theirmother went downhill fast and the patient is reported to not cope well with themothers illness/death. 

Reports the patient hadnt been eating lately with notedweight loss.  Additionally, the sisterreports the patient had been smoking and drinking more than usual lately.

Family Hx:

Paternal grandmother depression

Two maternal aunts bipolar disorder

Mother and father alcohol abuse

Father died from pancreatic cancer

Mother died from heart failure

3 living brothers, 3 living sisters, one deceased brotherwho had an AMI at age 34

Social Hx:

Divorced and remarried

Worked as a nurses aid and health insurance claims adjuster

Attends church regularly

Smoked 1ppd for 15 years

History of alcohol abuse with several DWI violations

History of IV drug use, not in the last 10 years

ROS:

Information from sister:

Neuro history of migraine headaches since late teens,takes Imitrex prn

SIGECAPS:

Sister reports: at times the patient is up all night particularly when bipolar symptoms not well controlled, the patient seemed tobe more depressed since the loss of their mother, does not believe the patientfelt guilty surviving parents, patient has been not been attentive to herpersonal hygiene, the patient appeared to be obsessing on parental loss, patientappeared to be losing weight and therefore suspect she was not eating well, patientseemed to not be engaging in typical daily activities; patient had notexpressed having suicidal ideations, had not expressed homicidal ideations  

Medications:                                                                                            

Lithium 600mg po Q AM and 600mg po Q HS

Sumatriptan 50-200mg po PRN

Allergies:

ASA swelling of face

Physical Examination:

General lethargic and slow to respond to questions; BP 110/72,P 66, RR 12, T 97.0, SpO2 on RA 95%, Ht 66 in, Wt 135 lbs, BMI 21.8

Integument skin pale, warm, dry; good turgor; severalcystic lesions on chin; no rashes, ecchymoses or petechiae noted

HEENT Head is normocephalic and atraumatic, pupils dilatedwith sluggish reaction to light, TMs gray and shiny bilateral, nares patent without discharge noted, no tonsillarenlargement, moist mucous membranes

Neck supple without adenopathy, no thyromegaly

Lungs CTA

Breasts deferred

Cardiovascular heart with RRR without murmur/gallop,multiple varicosities noted bilateral lower extremities

Abdomen soft, non-distended, active bowel sounds,non-tender, no organomegaly

Genitalia/Rectum deferred

Musculoskeletal no major limitations of ROM or grossabnormalities noted

Neurologic oriented to person, DTRs 2+ and equalbilateral, no localizing signs, CN II- XII grossly intact

Diagnostics Na 139 meq/L, K 3.7meq/L, Cl 108 meq/L, HCO3 23 meq/L, Bun 10 mg/dL, Cr 0.7 mg/dL, fasting Glu 102mg/dL, Ca 8.7 mg/dL, PO4 3.2 mg/dL, Protein 4.8 g/dL, Mg 2.0 mg/dL, AST 33IU/L, ALT 20 IU/L, GGT 82 IU/L, Alb 2.9 g/dL, TSH 4.1, Vit B12 203 pg/mL, Hgb12.2 g/dL, HCT 36.8 %;

Lithium 0.08meq/L

Urine dipstick 6.3 pH, SG 1.021, all other parametersnegative

Assessment:

You will be evaluating the subjective and objective datasets to determine the diagnoses for this patient encounter.

Plan:

The plan cannot be developed until the diagnoses areassigned.