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PART I Office Visit Scenario Gender: F Age: 69 Reason for Encounter: Productive cough and fever; patient is concerned that she may need medication for COPD which she has not needed for several years. Assessment: Viral pneumonia related to patient’s history of COPD. The patient’s blood sugars have been stable due to Type 2 diabetes for which she takes oral hyperglycemic agents. Plan: Treat with cough medicine with expectorant, take aspirin for fever, drink plenty of fluids to prevent dehydration. Questions to Answer: a. What are the patient’s symptoms? b. Why was the patient concerned about the symptoms? c. What was the principal diagnosis(es)? d. Should the symptoms be coded in addition to the final diagnosis? Yes or No. e. The type of DM is: f. Should the DM be coded as a secondary diagnosis? Yes or No.
SCIENCE
HEALTH SCIENCE
NURSING

 
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