Jonah Albertson, a 62-year-old male, was transported to the ED by EMS after an MVA. Patient was involved in a three-car accident while driving home.

WESTON HOSPITAL

629 Healthcare Way • SOMEWHERE, FL 32811 • 407-555-6541

PATIENT: ALBERTSON, JONAH

ACCOUNT/EHR #: ALBEJO001

DATE: 09/15/18

Attending Physician: Renee O. Bracker, MD

Jonah Albertson, a 62-year-old male, was transported to the ED by EMS after an MVA. Patient was involved in a three-car accident while driving home. Patient does not appear to have any injuries. Patient denies any pain or discomfort at this time. Patient is alert and oriented, but appears anxious.

VS: H: 6′ 1″, W: 192 lb., P: 94, R: 24, T: 99.1 F, BP: 90/60, SpO2 100% on room air.

Laboratory results 25 minutes after arrival:

pH: 7.5

PaO2: 195 mmHg

PaCO2: 32 mmHg

SaO2: 90%

HCO3: 20 mEq

Hgb: 13.9 gms

COHgb: 11.2%

With the level of carbon monoxide on the hemoglobin, the patient is placed on a nonrebreathing mask. COHgb has decreased to 7.1% and patient is breathing comfortably 4 hours after arrival. Patient is admitted for observation.

Three hours later, respiration becomes more rapid and labored. Patient shows extreme fatigue. Auscultation reveals fine crackles throughout both lungs. CXR shows bilateral infiltrates extending into all four lung quadrants.

Arterial blood gases are rechecked:

pH: 7.31

PaO2: 71 mmHg

PaCO2: 43 mmHg

SaO2: 89%

HCO3: 22 mEq

COHgb: 3.9%

Heart Rate: 79

Blood Pressure: 88/57

Dx: ARDS

P: Intubation and mechanical ventilation

 What is/are the correct diagnosis code(s)?

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