Patient History Analysis Jerry 3-3
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Feb 20, 2024
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Patient History Analysis
On the 30
th
of June in the year YYYY, Sally Pire arrived at Global Care Medical Center to seek medical assistance. Sally is a 60-year-old female who works as a nurse aide and has a medical history of arteriosclerotic cardiovascular disease, alcoholism, hypokalemia, and gastritis. Sally is a moderate smoker, but she denies drinking alcohol. In the past year, Sally suffered from a fractured wrist, which was a secondary injury resulting from excessive drinking.
Currently, Sally is taking three medications: Lanoxin, Lasix, and Klotrix. Her family medical history reveals that her mother’s side has a history of alcoholism, while her father has cardiovascular disease. Past Diagnosis
The patient’s past diagnosis has been identified as history. During the patient's last admission, their abnormal liver functions led to a diagnosis of alcoholism. In addition, they were found to have hypokalemia and gastritis. The patient also experienced mild angina, which led to the discovery of arteriosclerotic cardiovascular problems, evident in the sinus tachycardia. A cardiogram, cardiac enzymes, and electrolyte tests were ordered to confirm cardiovascular issues. The hypokalemia was diagnosed through a blood test from the chemistry profile, which showed a low potassium level. Similarly, gastritis was diagnosed through blood tests and by reviewing the patient's prescription history. Of alcoholism, hypokalemia, and gastritis. The diagnosis of alcoholism was made by abnormal liver functions, including lab studies after the last admission related to alcohol issues. The patient experienced some mild angina leading to arteriosclerotic cardiovascular problems found in the sinus tachycardia. A cardiogram was ordered, as were cardiac enzymes and electrolytes, to confirm cardiovascular issues. The
hypokalemia was diagnosed and found by blood test from the chemistry profile, resulting in a low potassium level. Gastritis can be detected by blood tests and the prescriptions she was taking.
Pneumonia is a severe lung infection caused by either a virus or bacterium. When it enters the body, the lungs react by becoming inflamed, which can cause the bronchioles and alveoli to fill with fluid and become solid. This leads to a lower respiratory infection. The normal function of the lungs is to filter oxygen and release carbon dioxide, known as respiration. However, when pneumonia occurs, the fluid in the lungs makes breathing much more complex and can cause chest pain, coughing, and fatigue. In some cases, pneumonia can result from the body's immune system being overwhelmed by a virulent pathogen or a large infectious microbial inoculum. This can cause a condition known as Cap when there is a defect in average host defense. There are several ways to acquire pneumonia, including community-acquired, nosocomial, hospital-acquired, ventilator-associated, and healthcare-associated infections. Community-
acquired pneumonia is the most common type and is transmitted through inhaling respiratory droplets from an infected person. Nosocomial pneumonia is acquired in a healthcare setting and is usually caused by antibiotic-resistant bacteria. Hospital-acquired pneumonia is nosocomial pneumonia that occurs more than 48 hours after a patient has been admitted to the hospital. Ventilator-associated pneumonia is a type of pneumonia that develops in people who are on a ventilator. Healthcare-associated pneumonia develops in people recently receiving healthcare services, such as those in long-term care facilities. It is essential to take appropriate precautions to prevent pneumonia, such as good hygiene practices, getting vaccinated, and avoiding exposure
to people who are sick. If you experience symptoms of pneumonia, seek medical attention immediately to receive appropriate treatment.
The patient had been taking three medications, namely Lanoxin, Lasix, and Klotrix, before their visit. Lanoxin, or digoxin, is an antidysrhythmic and inotropic agent used to treat tricuspid regurgitation. It works by inhibiting "catecholamine reuptake" at nerve terminals, which makes blood vessels more sensitive to endogenous or exogenous catecholamines. This results in an increase in the contractility of the heart, which helps in treating heart failure. Additionally, Lanoxin increases the sensitivity of the baroreceptors, leading to increased carotid sinus nerve activity and enhanced sympathetic withdrawal for any given increase in mean arterial pressure (Medscape).
Lasix, or furosemide, is classified as a loop diuretic and is used to treat congestive heart failure, liver cirrhosis, and renal disease. It works by blocking the reabsorption of sodium and chloride ions in the proximal and distal renal tubules and loop of Henle (Medscape). This leads to increased urine output, which helps to reduce fluid overload in the body. Lasix also helps reduce the heart's workload and improve its function.
Finally, Klotrix is used to treat hypokalemia, or low potassium levels in the blood. Potassium is an essential electrolyte critical in various physiological processes, including maintaining intracellular tonicity, transmitting nerve impulses, contracting cardiac, skeletal, and smooth muscle, and maintaining normal renal function. Klotrix is a potassium supplement given in capsule form to ensure adequate potassium levels. This helps treat conditions such as muscle weakness, fatigue, and irregular heartbeat due to low potassium levels.
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From June 30th through July 7, a patient was admitted to the hospital for pneumonia and arteriosclerotic cardiovascular disease. The patient also has a history of alcoholism, hypokalemia, and gastritis. Her previous admission was due to her liver function being compromised by excessive alcohol consumption, which consequently led to her other diagnoses. Given these pre-existing conditions, it is crucial to consider them while addressing other medical
concerns.
Upon admission on June 30
th
, the patient was diagnosed with provisional pneumonia and arteriosclerotic cardiovascular disease. Her chief complaint was shortness of breath, accompanied by cough, chills, sweating, and fever. Two x-rays confirmed the presence of pneumonia. The patient exhibited symptoms such as loss of appetite, fatigue, and elevated fever. The patient's liver function is directly related to her initial diagnosis of alcoholism. Her blood work for alkaline phosphatase, an enzyme that breaks down proteins, shows a result of 10.4 with a reference level of 50-136 U/I. Additionally, her total bilirubin, the substance for breaking down
red blood cells, is at 1.2, while the reference is just below 1.5. The lactate dehydrogenase, another enzyme in the liver, was also much higher at 206, with a reference between 100 and 190 (Mayo Clinic, 2019). While some liver issue-identifying tests were not performed, these results are sufficient to support the possibility of liver damage and a diagnosis. Another correct diagnosis is hypokalemia or low potassium, with her level at 3.4 and normal between 3.7-5.1 mEq/l. Although gastritis can be tested through blood work or endoscopy, the red blood cell count test only indicates 0-6/hpf with a reference of less than or equal to 5/hpf. Without much support for this diagnosis, confirming its cause is challenging.
Since the patient took an x-ray showing pneumonia and symptoms that line up with this disease, this likely is what the patient has. Her last diagnosis was for arteriosclerotic cardiovascular
disease, but there wasn't a CT scan or an MRA to see if that was an accurate diagnosis. She also had no complaints that lined up with this, but since her mother had it, that's likely why she was diagnosed. If these tests are conducted, she does have the possibility of having ACD, but it is unrealistic to claim this diagnosis this early.
The patient file contains several inaccuracies and inconsistencies. Using your medical terminology, anatomy, and physiology knowledge, articulate three issues you’ve identified.
Upon reviewing the patient's record, it has become apparent that several inconsistencies need to be addressed. Some of these inconsistencies may be due to inconsistent reporting, while others may be due to errors made by the physician. One of the most significant issues in the patient's record is the admission diagnosis, which reported both viral and bacterial pneumonia. Although the signs and symptoms of both types of pneumonia are mostly identical, it is crucial to determine which type the patient has to provide the appropriate treatment. Bacterial pneumonia is a serious infection that can lead to severe complications if left untreated. Fortunately, it can usually be treated with antibiotics. On the other hand, viral pneumonia is caused by a virus, and antibiotics are ineffective in treating it. Instead, patients with viral pneumonia are typically treated with supportive care and given time to recover independently.
To ensure that the patient receives the most appropriate treatment, it is crucial to identify the specific type of pneumonia they are suffering from. This will enable the medical team to provide the patient with the most effective care possible and increase their chances of a full recovery.
Please explain in detail how these identified issues could harm patient health and impact recordkeeping. Please use appropriate medical terminology, anatomy references, and everyday physiology concepts where applicable.
Moreover, discuss how these issues could affect the patient, coding system, and billing system if they were not detected and rectified on time, using the appropriate terminology.
Lastly, illustrate how you would address each issue, with specific details regarding what you would bring into the discussion and who would be responsible for the particular details of each issue in a real medical setting.
Crawford, J. (2018). What are the Signs of an Upper Respiratory Infection? Medical News Today. Retrieved from:https://www.medicalnewstoday.com/articles/323886#home-remedies
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