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Apply diagnosis/procedure codes according to current guidelines...

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Apply diagnosis/procedure codes according to current guidelines...

  • Apply diagnosis/procedure codes according to current guidelines (Bloom's Level 3)
    • Classification Systems
      • ICD (ICD-9-CM, ICD-10, ICD-10-CM/PCS)
    • Taxonomies
      • Clinical Care Classification (CCC)
    • Nomenclatures
      • CPT, DSM, RxNorm
    • Terminologies
      • LOINC, SNOMED CT
    • ipc58koper1.png

      Image transcription text

      Inpatient Consultation Patient Case Number: IPC58-Kopec, Greg Patient Name: Greg Kopec DOB: 08-21-59 Sex: M Date of Service: 09-01-XX Physician: Tyson Hill, MD Reason for Consultation: Abdominal mass History of Present Illness: This is a 59-year-old male who was seen and examined. He is resting in bed comfortably. The patient presented to ABC Hospital for abdominal pain with nausea and vomiting At this time, nausea and vomiting have resolved and the patient is passing flatus. The patient has a history of pancreatic mass for the past 6 years. The patient states he is to have surgery for this at XYZ Hospital. The patient currently denies nausea, vomiting, diarrhea, constipation, chest pain, shortness of breath, fever, chills. Review of Systems: A 12-point review of system is negative except for as listed in HPI. Medical History: Alcohol induced chronic pancreatitis, hin, alcohol dependence Allergies: Penicillin Social History: Tobacco dependence-10 cigarettes per day, currently drinks V4 pint of Vodka daily Family History: Non-contributory Vitals: Temperature 97.8OF Pulse 90 Respirations 18 Blood Pressure 135/80 Sp02 96 % on room air Laboratory Data: White blood count 10.9, hemoglobin 12.2, platelets 272,000. Sodium 140, potassium 3.9, chloride 102, CO2 23, BUN 5, creatinine 0.66, alkaline phosphatase 68, AST 16, ALT 16, albumin 3.1, lipase 20. Imaging Data: CT of Abdomen and Pelvis Impression: Mass noted in the head of the pancreas Peripancreatic inflammation, small mesenteric lymph nodes, air in the biliary tree, mild thickening of wall of the retroperitoneal, duodenal sweep with mild dilation of small bowel loop....
      ipc58koper2.png

      Image transcription text

      Assessment/ Plan: This is a 59-year-old male with known head of the pancreas mass unrelated to other pancreatic disease, uncertain etiology of this mass. Nausea and vomiting have resolved at this time. There is an need for emergent surgery The patient is passing flatus. We will follow up with GI recommendations. Currently weaning himself off of V's pint of vodka daily-alcohol dependency which is most likely responsible for this bout of pancreatitis with pancreatic insufficiency Patient also has hypertension....

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Answered by ssmnashrafi on coursehero.com
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