Discussion Unit 3 Review the SOAP note BELOW. Initial Post Use your lecture mate

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 to
address all components of the question, demonstrate critical thinking and
analysis and include peer-reviewed journal evidence to support the student’s
position.
***SOAP NOTE***
Chief Complaint:
Older sister reports – “Our mother died three weeks ago and
we lost our father several months ago. I
think that my sister was depressed and just wanted to be with them.”
History of Present
Illness:
31-year-old female who was brought to the hospital by
ambulance. She was found slumped over in
her car in front of the funeral home where memorial services for both her
father and mother had recently been held.
On the seat beside her were two empty bottles of sleeping pills, a Bible
opened to Psalm 23, and a note that read:
“I am going to be with mom and dad. It
is 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 unkempt
and she smelled as if she had not bathed in a long time. She was wearing a dirty orange T-shirt and
jeans.
PMH:
Depression when she was a junior in HS which led to
psychiatric admissions at 15 and 19 years of age. For these admissions she was treated with
antidepressants and psychotherapy.
Length of stay for both admissions was approximately 5 weeks. At age 19, following a suicide attempt, she
met her first husband in the psych ward of the hospital. Diagnosed with bipolar
disorder 6 years ago.
Information from
Sister:
Older sister reports ‘hard life’. Reports both parents were alcoholics. Parents would go to bars almost every night
and leave the 8 children in the care.
The children were eventually removed from the home. Some of the children went to the Catholic
girls’ home others were placed in “horrible” foster homes where they were
subjected to physical and sexual abuse.
Reports numerous siblings, including the patient, have been
through several detoxification centers for alcohol abuse.
Patient is in her second marriage with 3 daughters – 2 from
the first marriage and 1 from the current marriage.
Reports that after having her third baby the patient went
into a ‘terrible depression’. The
patient was under the care of a psychiatrist for this depression and was placed
on an anti-depressant after about 3 months of being under the psychiatrist’s
care. After 3 weeks of being on this
anti-depressant the patient is reported as having gotten ‘really weird’;
patient was staying up all night pacing around her house and talking to people
on the phone, she would go on shopping sprees for 2-3 days at a time and max out
all her credit cards. The patient
finally crashed and was taken to the hospital by her family and it was during
this admission, 6 years ago, that the patient was diagnosed with bipolar
disorder. Sister reports the patient has
been on Lithium since being diagnosed with bipolar disorder.
Reports their father had been sick for a while so his death
was not unexpected. However, their
mother went downhill fast and the patient is reported to not cope well with the
mother’s illness/death.
Reports the patient hadn’t been eating lately with noted
weight loss. Additionally, the sister
reports 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 brother
who had an AMI at age 34
Social Hx:
Divorced and remarried
Worked as a nurse’s 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 to
be more depressed since the loss of their mother, does not believe the patient
felt guilty surviving parents, patient has been not been attentive to her
personal hygiene, the patient appeared to be obsessing on parental loss, patient
appeared to be losing weight and therefore suspect she was not eating well, patient
seemed to not be engaging in typical daily activities; patient had not
expressed 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; several
cystic lesions on chin; no rashes, ecchymoses or petechiae noted
HEENT – Head is normocephalic and atraumatic, pupils dilated
with sluggish reaction to light, TMs gray
and shiny bilateral, nares patent without discharge noted, no tonsillar
enlargement, 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 gross
abnormalities noted
Neurologic – oriented to person, DTRs 2+ and equal
bilateral, no localizing signs, CN II- XII grossly intact
Diagnostics – Na 139 meq/L, K 3.7
meq/L, Cl 108 meq/L, HCO3 23 meq/L, Bun 10 mg/dL, Cr 0.7 mg/dL, fasting Glu 102
mg/dL, Ca 8.7 mg/dL, PO4 3.2 mg/dL, Protein 4.8 g/dL, Mg 2.0 mg/dL, AST 33
IU/L, ALT 20 IU/L, GGT 82 IU/L, Alb 2.9 g/dL, TSH 4.1, Vit B12 203 pg/mL, Hgb
12.2 g/dL, HCT 36.8 %;
Lithium 0.08meq/L
Urine dipstick – 6.3 pH, SG 1.021, all other parameters
negative
Assessment:
You will be evaluating the subjective and objective data
sets to determine the diagnoses for this patient encounter.
Plan:
The plan cannot be developed until the diagnoses are
assigned.