Kaplan University, Davenport HI253_Unit_10_Assignment_1. Questions and Answers

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Scenario A (Questions 1-8): "This 85-year-old man is admitted for treatment of pneumococcal pneumonia. At the time of admission, he was also complaining of severe back pain with no recent accident o... r trauma. IV antibiotics were started for the pneumonia, pain medication for the back pain, and a CT scan of the lumbar spine was completed. The radiology report indicated that the patient had a fracture of the L4-5 vertebrae, however, the attending physician did not note these findings in the health record. Discharge diagnosis was documented as: Pneumococcal Pneumonia with severe low back pain." Scenario B (Questions 9-13): "A 79-year-old woman was admitted with an acute exacerbation of both Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD). She was appropriately treated for both conditions. The day after admission, an echocardiogram was done to determine the severity of the patient’s congestive heart failure. The echocardiogram indicated that the patient has both systolic and diastolic heart failure. Discharge diagnosis: Acute CHF exacerbation, COPD exacerbation." Scenario C (Questions 14-17): "A 30-year-old male was admitted with severe abdominal pain and nausea. The patient has not experienced any vomiting. Because of the nausea, he was dehydrated and treated with IV fluids. The patient also has a history of Crohn’s disease. Abdominal X-rays were completed which showed significant inflammation in the sigmoid intestine. The attending physician did not document a causal relationship between the abdominal pain and the patient’s Crohn’s disease. Final diagnosis: Severe abdominal pain with nausea, dehydration and a history of Crohn’s disease.” Scenario D (Questions 18-20): "A 75-year-old gentleman was admitted for control of his atrial fibrillation. Two days after admission the attending physician documented the presence of a decubitus ulcer on the buttocks. After thorough review of the health record, the nursing intake documentation did identify the presence of the decubitus ulcer and stated it was stage II. Final diagnosis: Atrial fibrillation with decubitus ulcer on buttocks." Scenario E (Questions 21-24): "A 79-year-old female was admitted with acute shortness of breath and the patient also carries a diagnosis of CHF and COPD. The emergency room physician suspected pneumonia but this was ruled out. The consulting physician felt that the patient’s symptoms were ‘more heart failure related’; however, the progress note on 7/9/09 at 0830 hours by the attending physician noted that he did not feel the shortness of breath was related to congestive heart failure due to lack of clinical findings. The final progress note on 7/9 by the Heart Failure Clinic states that the shortness of breath was due to volume overload. Scenario E (Questions 21-24): "A 79-year-old female was admitted with acute shortness of breath and the patient also carries a diagnosis of CHF and COPD. The emergency room physician suspected pneumonia but this was ruled out. The consulting physician felt that the patient’s symptoms were ‘more heart failure related’; however, the progress note on 7/9/09 at 0830 hours by the attending physician noted that he did not feel the shortness of breath was related to congestive heart failure due to lack of clinical findings. The final progress note on 7/9 by the Heart Failure Clinic states that the shortness of breath was due to volume overload. B. VistA Simulation: VistA is a comprehensive computerized patient record system that was developed by the U.S. Department of Veterans Affairs in 1997 to integrate the Veterans Health Administration medical centers, outpatient clinics and nursing homes across the country. Since its inception, VistA has been adopted by other non-VA healthcare provider organizations. There is a VistA simulation built into AHIMA’s VLab. You will be able to view various screens and functions through the VistA simulation. [Show More]

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