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

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Asked by LieutenantFireFlamingo8 on

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
  • ipc53malone1.png

    Image transcription text

    Inpatient Consultation Patient Case Number: IPC53- Malone, Axel Patient Name: Axed Malone DOB: 11-13-57 Sex: M Date of Service: 03-04-XX Physician: Richard Henderson, MD Reason for Consultation: Right great the wound History of Present Illness: This is a 61 yo female who presented to the hospital last night with complaints of right toe pain. Upon admission, she has a gangrenous right great toe. The patient states that the wound has been there for approximately 7 days, though I suspect it has been longer. Denies any fevers at home. She has DMII. She was supposed to be taking medication for her diabetes including Metformin and Insulin, however, she has not taken either medication for at least a year due to an insurance issue and not being unable to pay for it. She has not seen a doctor since then. She takes no medications at home. Denies any recent fevers or chills. Denies any drainage from the foot. Does not remember how she obtained a wound on her foot to start with. Allergies: NKDA Medical History: DM, hin Surgical History: Includes tonsillectomy, left great toe amputation, and endometrial biopsy for postmenopausal bleeding. Family History: Non-contributory Review of Systems: A 12-point review of systems is negative unless stated otherwise in the above HPL Vitals: Temperature 98 5-F Pulse 80 Respirations 20 Blood Pressure 106/60 Sp02 98 % on room air Physical Examination: GENERAL: No acute distress. Alert and oriented x.3. HEENT: Normocephalic, atraumatic. No jugular venous distention. No tracheal deviation. LUNGS: Nonlabored. dear to auscultation bilaterally...

    Image transcription text

    HEART: Nontachycardia. ABDOMEN: Morbidly obese. EXTREMITIES: Bilateral upper extremities no clubbing, cyanosis, or edema. Left lower extremity, no clubbing, cyanosis or edema. Noted previous left great toe amputation. Right lovwer extremity right great toe with wet gangrene, odor, purulent drainage surrounding very erythematous skin and cellulitic tissue, tracks to the mid portion of her forefoot. Cellulitis extends to the second and third toes as well. Numbness and tingling of byl extremities Laboratory Data: Hemoglobin 11.2, hematocrit 343, white blood cells 14 2, platelets 287. Sodium 130, potassium 40, chloride 96, bicarbonate 18.9, BUN 23, creatinine 1.51. Lactate 1.2 Imaging- X-ray of Right Foot Impression: Advanced osteomyelitis of the distal phalanx of the big toe with surrounding soft tissue swelling and gas. Impression: 1. Diabetic peripheral vascular disease, type 2, with gas gangrene of the right great the with osteomyelitis of the distal phalanx. 2. Cellulitis of the right toe 3. Diabetes mellitus, uncontrolled-hyperglycemic and diabetic polyneuropathy. 4. Morbid obesity. 5. Hypertension. 5. Peripheral neuropathy. 6. Medication noncompliance due to financial reasons. Plan: 1. IV antibiotics, Zosyn and vancomycin. 2. A.m. labs 3. Non 4. To Ol now for debridement and probable amputation of at left the great toe. 5. Discussed with attending, who agrees with above. Electronically Signed By: Richard Henderson, MD...

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