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
Image transcription text
Inpatient Consultation
Patient Case Number. IPC28- Soutar, Dennis
Patient Name: Dennis Soutar
DOB: 10-15-57
Sex: M
Date of Service: 09-03-XX
Physician: Dennis Mock, ND
Reason for Consult: Concern for colonic ischemia
History of Present Illness:
Dennis Soutar is a 61 yo male admitted after an aborted aortomesenteric bypass due to aspiration
on anesthesia induction. He has chronic mesenteric ischemia diagnosed about 5 years ago and is s/p
SMA stent, balloon angio SMA stent, and re-stent. He developed postprandial and pain. He has
known celiac occlusion. He was stabilized and then was taken for supraceliac aorta to SMA and hep
artery grafts.
He underwent CT scan today for increasing WBC (30) and found to have right colon thickening
concerning for ischemia.
Medical History: Psoriasis, hin, hyperlipidemia, DM, PVD Social History: Former smoker,
0.5ppd for 30 years Allergy: Statins
Vitals:
Temperature
98.6-F
Pulse
78
Respirations
20
Blood Pressure
117/90
Sp02
98% on room air
Physical Examination Constitutional: intubated
CV: RRR
Chest: ventilated, breath sounds b/1
Abdomen: distended, midline incision with dermabond, unable to determine if the patient is having
TTP due to AMS
Labs Reviewed:
WBC 30.12
Hb 7.6
pit 46
BUN/Cr 29/22 AST/ ALT1008/1889 LA 1.4...
Image transcription text
Imaging
CT of Abdomen/ Pelvis
1. Evolving splenic and hepatic infarction with perihepatic, perisplenic, and upper mesenteric
hematoma. Findings show evidence of celiac artery occlusion given the high degree of stenosis
seen on prior CT scan.
2. Bowel wall thickening of the hepatic flexure, highly concerning for bowed ischemia. No evidence
of pneumatosis of intraperitoneal free air.
3. Large pleural effusions with associated lower lobe atelectasis. Layering hyperdense material in the
right pleural effusion likely represents hematoma.
Impression:
61 yo male with acute mesenteric/colonic ischemia s/p supraceliac sorto-SMA and aorto-hep
artery bypass. Increasing leukocytesis and CT scan are concerning for colonic ischemia.
2. Celiac artery compression syndrome.
3. Hypertension.
4. Hyperlipidemia.
5. Type 2 DM with peripheral vascular disease....
Answer & Explanation
Solved by verified expert
Answered by ssmnashrafi on coursehero.com
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