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Respiratory System – Analyzing a Progress NotePart 1Using the following progress note, define the highlighted terms within the chart provided. This patient returns to the Pulmonary Medicine Clinic for a follow-up evaluation of COPD and emphysema. Progress Note:Subjective: The patient is an 85 y.o. female who returns to the clinic for a follow-up evaluation of COPD and emphysema. At the present time, respiratory status is relatively stable. She is still short of breath with activity, but mostly her pulmonary disease has not changed significantly since her last visit. She does have an occasional cough and a small amount of sputum production. No fever or chills. No chest pains.Objective: Vital signs 99.8 orally, 152/80, pulse 80, respirations 16. Nasal mucosa was mild to moderately erythematous and edematous. Oropharynx was clear. Pulse ox 90% on room air. Assessment: Chronic obstructive pulmonary disease/emphysema, severe but stable. Mild hypoxemia.Plan: Portable chest x-ray, complete blood count, arterial blood gases: Start oxygen at 1 Liter, recheck pulse ox after aerosol. Consult a pulmonologist for further orders.Lisa Jones, PA*Do not forget to include the sources for your definitions.40 Points: 1 point for Medical term, 2 points for Definition, and 1 point for SourcesMedical termDefinitionSources1.2. 3. 4. 5. 6. 7.8.9.10.Part 2Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.30 points: 10 for each correct answer. Medical termMedical codeCOPD, acuteJ44.9 COPD unspecifiedJ44 Other chronic obstructive pulmonary diseaseJ45.901 Asthma, unspecified type, with (acute) exacerbationJ44.1 Chronic obstructive pulmonary disease with (acute) exacerbationRespiratory failure, with hypoxia J22 Unspecified lower respiratory infectionJ96.11 Chronic respiratory failure with hypoxiaJ96.12 Chronic respiratory failure with hypercapniaJ96.91 Respiratory failure, unspecified with hypoxiaEmphysema J98.2 Interstitial emphysemaJ18.9 Pneumonia, unspecified organism J43.9 Emphysema, unspecifiedJ43.0 MacLeod’s syndrome – Unilateral pulmonary emphysemaReferencesCenters for Medicare & Medicaid Services (23 Oct. 2015). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.” ................
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