Record Number: 82-50-77
Age: 81
Gender: Female
Length of Stay: 2 Days
Service Type: Inpatient
Discharge Status: To Long-Term
Care
Diagnosis/Procedure: Severe Peripheral Venous Cellulitis
Lower Extremities, Bilateral.
DISCHARGE SUMMARY
PATIENT: MYRA INPATIENT
RECORD NUMBER: 82-50-77
ADMITTED: 03-15-XX
DISCHARGED: 03-17-XX
PHYSICIAN: DR. ALEX, M.D.
DISCHARGE DIAGNOSIS: Severe peripheral venous cellulitis
with 4+ edema lower extremities (bilateral).
HISTORY: This patient is an 81-year-old female
admitted because of severe edema of her lower extremities and
developing leg ulcers bilaterally.
LABORATORY DATA: SMAC showed glucose of 132, SGPT
29, albumin 3.2, cholesterol 258. The rest of the SMAC was normal.
Urinalysis was physiologic. Hemoglobin 13.6, hematocrit 40.7, white
count was 4,800 with a normal differential. Platelets were
adequate. Red blood cell morphology was essentially normal.
HOSPITAL COURSE: The patient was admitted to the
hospital to treat bilateral leg 4+ pitting edema and weeping
infections of the sacrum and of both feet. Cultures of both the
sacrum and feet were performed with cultures returning positive for
staphylococcus aureus, methicillin susceptible, and Group
A streptococcus. The patient was started on IV
Tetracycline and Lasix. Edema of her feet cleared rapidly with
simple elevation and two doses of Lasix. After discussion with the
family, it was felt that long-term care placement was the most
appropriate place to care for this patient.
DISCHARGE PLANS: Patient was transferred to the
local long-term care facility with orders to remain mostly at bed
rest with the legs elevated along with an order for heat lamp to
the sacral area qid. Tetracycline treatment will continue as
ordered for the next 5 days with review at that time. I suspected
mild depression in the patient with orders to watch for increasing
signs or symptoms with intervention as needed. The patient will be
followed in the long-term care facility.
DR. ALEX, M.D.
Electronically authenticated by Dr. Alex, M.D., 03-18-xx 856
HISTORY AND PHYSICAL
PATIENT: MYRA INPATIENT
RECORD NUMBER: 82-50-77
ADMITTED: 03-15-XX
DISCHARGED: 03-17-XX
PHYSICIAN: DR. ALEX, M.D.
CHIEF COMPLAINT: Severe peripheral venous
cellulitis with 4+ edema lower extremities
(bilateral).
HISTORY OF PRESENT ILLNESS: This patient is an
81-year-old Caucasian female who lives alone and recently has lost
her husband. The patient's daughter states that activities of daily
living are accomplished only because of her help to the patient.
The daughter checks on her mother three times a day to assure
meals, baths, and general living activities. It is noted that the
patient chooses to sleep in her chairs in the living room and not
in her bed. The patient's legs reveal 4+ pitting edema and very
swollen as her feet are down all day. She has weeping infections of
both the sacrum and of both feet. The patient is alert and awake
but does not seem interested in helping herself get better.
Home health has been seeing the patient on a bi-weekly basis but
has stated that that the patient really cannot be managed at home
any longer and needs to have other living arrangements for her own
safety and health. She has been on no other medications.
ALLERGIES: She is allergic to Penicillin. Does not tolerate
Codeine.
MEDICATIONS: Tetracycline. Hormone shot and Thyroxin.
FAMILY HISTORY: Family history of heart disease, diabetes, skin
cancers.
PAST HISTORY: History of stroke eight months ago with resultant
gait ataxia. She has had an appendectomy, total abdominal
hysterectomy, a T&A, varicose vein operations and
hemorrhoidectomy. She has had an adenomatous polyp with villous
features removed from her colon in September. She has had skin
cancers removed from her legs. Hypothyroidism.
REVIEW OF SYSTEMS: At this time, the patient has no complaints. She
is a very reluctant patient and does not cooperate for examination.
Patient denies any physical problems at this time.
PHYSICAL EXAMINATION:
GENERAL: Patient is awake, alert and noncooperative. There is
weeping lesions of both feet and sacrum.
HEENT: Normocephalic without lesions. Fundi normal. She is wearing
her dentures and does wear glasses. Hearing is good.
LUNGS: Clear to auscultation and percussion. No breast masses are
noted.
HEART SOUNDS: Normal. Rhythm is regular.
ABDOMEN: Palpation of the abdomen reveals no masses. Bowel sounds
are normal. There are no bruits.
PELVIC and RECTAL: Not attempted with this noncooperative patient.
There is an area of skin breakdown over the sacrum and both feet
are 4+ edematous with weeping from the dorsum of the feet.
ADMITTING DIAGNOSIS:
1. Severe edema with secondary infections of wounds of the sacrum
and feet.
2. Cerebrovascular disease with previous stroke.
3. Hypothyroidism on replacement therapy.
PLAN: Admit for treatment of edema and weeping lesions of feet and
sacrum.
DR. ALEX, M.D.
Electronically authenticated by Dr. Alex, M.D., 03-15- xx 8567
Identify the following:
LIST ICD-10-CM codes for:
Principal Diagnosis:
Any secondary diagnosis:
LIST ICD-10-PCS codes for:
Principal Procedure:
any secondary procedure:
ICD -10-CM code is the tenth classification of diagnosis and is used by the healthcare workers to a diagnosis . It is also used by the insurance company to code diagnosis for reimbursement purpose .
CPT code is the current procedural terminology used to code procedures .
Principal diagnosis - severe peripheral venous cellulitis with 4+edema( Bilateral )
Secondary diagnosis - infection of wound on sacrum and feet , cerebrovascular disease , hypothyroidism
ICD -10-CM code for :-
Severe peripheral venous cellulitis with 4+edema (Bilateral) - L03.119
Infection of wound - S81
Cerebrovascular disease - I 67.9
Hypothyroidism - E03.8
ICD -10-PCS code for :-
Principal procedure - culture of both sacrum and feet wound - 87070
Secondary procedure - nil
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