2.Hypotension and hypovolemia causing decrease renal perfusion which lower urine output. Low urine output is sign of Acute kidney injury.
3.
CRITICAL THINKING ACTIVITIES 1. Prioritize the following list of preopera Deinritize the following list of preoperative...
Assign the CPT code for all 3 operative reports Assignment #1 PREOPERATIVE DIAGNOSIS: Appendicitis. POSTOPERATIVE DIAGNOSIS: Appendicitis, nonperforated. PROCEDURE PERFORMED: Appendectomy. ANESTHESIA: General endotracheal. PROCEDURE: After informed consent was obtained, the patient was brought to the operative suite and placed supine on the operating table. General endotracheal anesthesia was induced without incident. The patient was prepped and draped in the usual sterile manner. A transverse right lower quadrant incision was made directly over the point of maximal tenderness. Sharp dissection...
Q: Need help to Code ICD-10 CM for the diagnoses (primary & secondary) and all the CPT code for the procedure for following outpatient surgery case with explanation ORTHOPAEDICS HISTORY AND PHYSICAL DATE OF CONSULT: 11/8/2013 PRIMARY CARE PHYSICIAN: Jody L. Mathie, M.D. CHIEF COMPLAINT: Retained hardware left femur HISTORY OF PRESENT ILLNESS: is a 9 year old accompanied by his parents for history and physical examination. has a history of left femur fracture treated with closed reduction, flexible IM...
Discussion: Week 4 All Sections 66 unread replies.1111 replies. Scenario 1 A nurse is reviewing the latest lab results for a 44-year-old patient admitted with fever of unknown origin (though meningitis was ruled out). The lab slip indicates that the patient’s white blood cell count is elevated. The nurse calls the physician’s office to discuss the lab results, but the office is closed and the nurse is asked to leave a voicemail message. What should the nurse do? Scenario 2...
Health Record Face Sheet Record Number: 76-50-77 Age: 31 Gender: Male Length of Stay: 1 Day Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Left Inguinal Hernia Herniorrhaphy DISCHARGE SUMMARY PATIENT: WALLACE INPATIENT Record Number: 76-50-77 ADMITTED: 06-03-XX DISCHARGED: 06-04-XX PHYSICIAN: DR. ALEX, M.D.DIAGNOSIS: Left inguinal hernia. PROCEDURE: Herniorrhaphy. HISTORY OF THE PRESENT ILLNESS: : The patient is a 31-year-old Caucasian male who was in his usual state of health until approximately 1-2 weeks prior to admission at which time...
1) ICD-10-CM PRINCIPAL DIAGNOSIS? 2)ICD 10 CM ADDITIONAL DIAGNOSIS? 3)ICD 10 CM ADDITIONAL DIAGNOSIS? 4) )ICD 10 CM ADDITIONAL DIAGNOSIS 5)ICD 10 PCS PRINCIPAL PROCEDURE? 6)ICD 10 PCS ADDITIONAL PROCEDURE? Code in proper sequence! Discharge Summary Principal Diagnosis: Morbid obesity Principal Procedure: Open Roux-en-Y gastric bypass, removal of gastroplasty ring, gastric (G) tube prior placement; gastroscopy History of Present Illness: The patient is a 55-year-old white female with a history of gastroplasty ring placement in 1979 who comes to Dr....
Code the first operative report, include any CPT surgery code(s), anesthesia code(s), and any modifiers applicable. (20 points) Code the E&M code for the second office visit. 1. Description: Bilateral open Achilles lengthening with placement of short leg walking cast. PREOPERATIVE DIAGNOSIS: Idiopathic toe walker. POSTOPERATIVE DIAGNOSIS: Idiopathic toe walker. PROCEDURE: Bilateral open Achilles lengthening with placement of short leg walking cast. ANESTHESIA: Surgery performed under general anesthesia. A total of 10 mL of 0.5% Marcaine local anesthetic was used....
Project 7-1: Classify Patient Incidents According to Policy This primary source of information on patient safety will be used to analyze the incidents according to level of severity. The following policies define the three categories of severity Policy on Level I Event: An incident that resulted in patient death or serious short or long-term (6 weeks or more) disability or harm Policy on Level II Event: An incident that resulted in minimal short-term patient disability or harm Policy on Level...
Record Number: 84-50-77 Age: 53 Gender: Male Length of Stay: 6 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Atherosclerosis Coronary Arteries. Unstable Angina. Double Coronary Artery Bypass. DISCHARGE SUMMARY PATIENT: JED INPATIENT RECORD NUMBER: 84-50-77 ADMITTED: 06-15-XX DISCHARGED: 06-20-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Atherosclerosis coronary arteries with chronic total occlusion. Unstable angina. Congestive heart failure, combined systolic and diastolic, chronic. PROCEDURE: Coronary artery bypass graft x 2. HISTORY OF THE PRESENT ILLNESS: The patient is a 53-year-old...
Health Record Face Sheet Record Number: 77-50-77 Age: 76 Gender: Male Length of Stay: 6 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Hemoptysis Fiberoptic bronchoscopy with biopsy DISCHARGE SUMMARY PATIENT: JARED INPATIENT RECORD NUMBER: 77-50-77 ADMITTED: 06-15-XX DISCHARGED: 06-21-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Hemoptysis. Hypertension. Atelectasis. PROCEDURE: Fiberoptic bronchoscopy x 2 with biopsy. HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old white male admitted to the hospital with hemoptysis. The patient states that approximately three...
Code the following reports utilizing CPT codes, and apply any applicable modifiers. Assignment #1 Description: The right upper lobe wedge biopsy shows a poorly differentiated non-small cell carcinoma with a solid growth pattern and without definite glandular differentiation by light microscopy. GROSS DESCRIPTION: A. Received fresh labeled with patient's name, designated 'right upper lobe wedge', is an 8.0 x 3.5 x 3.0 cm wedge of lung which has an 11.5 cm staple line. There is a 0.8 x 0.7 x...