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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
    • IPC28SOUTAR1.png

      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....

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