What is the principle diagnosis

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Reference no: EM133265915

Case Study #1

Review the medical record below. Determine the principle and any secondary diagnosis. Code the scenario by answering the questions below.

Questions

1. What is the principle diagnosis

2. What is (are) the secondary diagnosis

3. What code(s) are assigned for this admission?

4. What is the POA Indicator for each diagnosis code?

Medical Record

Chief Complaint: History of nausea with severe vomiting for the past two to three days. Diabetes mellitus was diagnosed at the age of 12 years.

Hospital Course: The 31-year-old male patient has a history of type 1 diabetes mellitus and is on 15 units of NPH and 10 of Regular in the morning, and 10 units of NPH and 5 of Regular in the evening. The patient started having symptoms of nausea. The patient at the same time had increased frequency of urination and polydipsia with evidence of uncontrolled diabetes. The patient was severely dehydrated on admission. There was no evidence of thrombophlebitis, varicosities, or edema on examination of the extremities. The patient was hydrated and, as a result, his blood sugar decreased from more than 600 to normal levels. The patient was discharged with the diagnosis of diabetic ketoacidosis, type 1.

Reference no: EM133265915

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