What is the rationale for this case? What is the rationale for the ICD-10-CM codes for the case? Admited: 1/2/20XX Discharged: 1/2/20XX HISTORY OF PRESENT ILLNESS: This patient is a 31-year-old male, who was brought to the Emergency Department on the afternoon of admission following an apparent syncopal episode, which occured one time. He states that he had been in Chicago with his family. He started driving home and he has no recollection of events from that time until he was brought by EMS to the Emergency Department. He states he has been under "a great deal of stress" over the past several days and has been "existing on root beer and cigarettes" for the past 4-5 days. He denies any nausea, vomiting or diarrhea. He has had no fever or chills. He states he has had a dry cough over the last several days, but otherwise has felt pretty much his normal self. Vital signs in the Emergency Department showed blood pressure 151/96, pulse 110, respirations 22 and temperature is 98.7. O2 saturation is 99% on room air. His Emergency Room evaluation included a urinalysis, which was unremarkable. A drug screen is positive for opiates, otherwise within normal limits. CBC was essentially normal. Serum chemistry shows a potassium of 3.4, ALT is mildly elevated at 68. The remainder of his serum chemistry was within normal limits. A blood alcohol was less than 5; however, because of his syncopal episode, it was elected to admit him to Acute Care for observation. PAST MEDICAL HISTORY: This gentleman's past medical history is essentially negative. PAST SURGICAL HISTORY: Negative. MEDICATIONS: He takes no routine medications. ALLERGIES: He is allergic to penicillin. FAMILY HISTORY: Essentially negative. REVIEW OF SYSTEMS: Essentially negative as well. PHYSICAL EXAMINATION: GENERAL: At the time of my exam, he is awake, alert, oriented and cooperative with his exam. HEENT: Head is normocephalic without masses, scars or lesions. Hair distribution is normal for age and sex. Ears, external auditory canals are patent without erythema or exudate. Tympanic membranes are pearly gray in color and exhibited normal cone of light. Eyes, ocular adnexa are unremarkable. There is no scleral icterus or hyperemia noted. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Funduscopic exam is unremarkable. Nose, nares are patent bilaterally. Mouth, oral mucosa is moist. There are no oral lesions noted. Posterior pharynx is free of erythema or exudate. NECK: Supple. No anterior or posterior cervical lymphadenopathy. Trachea is midline and freely movable. Thyroid is nonpalpable. Carotid pulses 2/4+, equal bilaterally, exhibited good upstroke and no bruits to auscultation. CHEST: Symmetrical. Exhibits good excursion on deep inspiration. Breath sounds are vesicular and bronchovesicular in all lung fields. HEART: Regular rate and rhythm without murmurs, clicks, rubs or gallops. There is no precordial heave or thrill noted. PMI is approximately at fifth intercostal space at the midclavicular line. ABDOMEN: Mildly obese and soft. Bowel sounds are active in all 4 quadrants on auscultation. There are no unexpected areas of tympani or dullness to percussion. No masses or organomegaly are appreciated by palpation. The abdomen is nontender. EXTREMITIES: There is no cyanosis, clubbing or edema noted. Pulses; brachial, radial, femoral, popliteal, posterior tibial and dorsalis pedis pulses are all 2/4+ and equal in all 4 extremities. Deep tendon reflexes are 2/4+ and equal in all 4 extremities. VITAL SIGNS: Height on admission is 6 feet 1 inch. Weight is 223. His vital signs have remained stable. He is afebrile. He has had no further syncopal episodes and is felt that he can be discharged at this time and managed on an outpatient basis. He will be given a prescription for hydroxyzine 25 mg 1 every 6 hours p.r.n. for anxiety. He is encouraged to eat a healthy diet and increase his fluids over the next few days and I have asked him to follow up with me in the office on an as needed basis.
1.He may be having stress induced hypertension and bcz of alteration in ALT he might be having liver disease
2.F40-F48 stress related disorders
What is the rationale for this case? What is the rationale for the ICD-10-CM codes for...
What is the rationale for this case? What is the rationale for the ICD-10- codes for this case? HPI: 9 Yrs 2 Mos female established patient who presents to the office with compliants of throat pain and neck pain since yesterday afternoon. Better with motrin (12.5ml, last dose at 0630 this morning). Worse with sitting down or laying down. No abdominal pain. Has slight headache at base of head. No new rashes (follows with dermatology for eczema, given a cream...
what is the rationale for this case? What is the rationale for the ICD-10- codes for this case? Dear Dr. X, as you know, the patient is a 53-year-old male who presented to the Emergency Room on the day of this consult complaining of burning right lower quadrant pain. On exam, he was found to have wheezing, coughing to go along with his right lower quadrant pain. You are kind enough to refer him for general surgical consultation for this...
what is the rationale for this case? What is the rationale for the ICD-10- codes for this case? Dear Dr. X, as you know, the patient is a 53-year-old male who presented to the Emergency Room on the day of this consult complaining of burning right lower quadrant pain. On exam, he was found to have wheezing, coughing to go along with his right lower quadrant pain. You are kind enough to refer him for general surgical consultation for this...
What is the professiona code and cpt icd-10-cm codes for this case? Reason for Visit: General history and physical, yearly exam, seen a year ago by me. HPI: Harry is here today for a general history and physical. He reports that he is currently feeling well and has no major concerns today. Chronic Medical Problems: Positive history of hypertension. Currently takes hydrochlorothiazide 25 mg 1 by mouth daily for this. He reports no headache, no visual changes, no chest pain,...
What is the rationale for this case? What is the rationale for the ICD-10-CM secondary codes? HPI: Patient is 6 Yrs male who presents to the ER with left ankle injury last night. Twisted his ankle while playing. No having pain and swelling of left lateral ankle. Able to ambulate but with a limp. No numbness or tingling. No other injuries. Past Medical History: Past Medical History: ENVIRONMENTAL ALLERGIES Past Surgical History: No past surgical history on file. Immunizations: Immunizations...
What is the rationale for this case? what is the rationale for the secondary diagnosis codes? HPI: 4 Yrs 4 Mos male with pmh sig for chronic constipation who presents with 10 days of abdominal pain. Seen by PMD and diagnosed with viral etiology. Abdominal pain continued to come and go and was seen at Westside Hospital ED and given zofran, miralax-8 grams only given once. and discharged home. Seen 1 day PTA in ED at Mary Children’s Hospital and...
What is the rationale for this case? what is the rationale for the secondary diagnosis codes? HPI: 4 Yrs 4 Mos male with pmh sig for chronic constipation who presents with 10 days of abdominal pain. Seen by PMD and diagnosed with viral etiology. Abdominal pain continued to come and go and was seen at Westside Hospital ED and given zofran, miralax-8 grams only given once. and discharged home. Seen 1 day PTA in ED at Mary Children’s Hospital and...
What is the professional code and the cpt ICD-10-cm codes for this case? HPI: The patient is an 11-year-old child who was admitted for abdominal pain. Today I am completing the initial H & P. He was sent over from his primary care physician’s office because of this pain. Mom states that the pain started today at about 1400 in the afternoon when it just suddenly hit him. He started to bend over and writhe in pain. It seems to...
Case Presentation Miguel is a 63 year male patient who presented to the emergency department complaining of a week history of progressive dyspnea, wheezing and productive cough with whitish phlegm. He denies any recent cold or flu-like symptoms. Miguel also denies any fever or chills. He has been using his Ventolin MDI but symptoms are worsening. On assessment you noted that the client developed severe dyspnea with exertion. He was assuming a tripod position and became pale and diaphoretic with...
T.J. is a 53-year-old man that has just presented to the Emergency Department for a rash, shortness of breath and feeling very weak. He tells you that he just finished a shrimp dinner at the local restaurant when the symptoms began and they have been getting steadily worse. He states the first thing he noticed was his lips tingling and then the rest of his mouth. Over the next few minutes he continued to feel worse when his wife noticed...