Question

History of Present Illness: The patient is a 59 year old male who was brought into the hospital by his wife for problems associated with weakness, illness, general inability to ambulate, swollen calf, confusion, and a 25 pound weight loss. This has been ongoing for two months. Initial intake X ray showed evidence of a mass in the right lung. The patient was admitted. A Doppler ultrasound of the legs failed to reveal phlebitis. We are asked to see this patient in consultation by Dr. Williams at this time.

Medical History: The patient denies any history of coronary disease, diabetes, hypertension, but has had a past history of gastrointestinal abnormalities.

Surgical History: Fractured right hip about 10 years ago, with internal fixation.

Social History: This patient’s industrial history is somewhat in construction, and has some asbestos dust and biological exposures. These is an 80 pack-year exposure.

Review of Systems: Review includes some headache, loss of memory, loss of appetite, nausea, and dyspepsia. He reports that he has coughed up a modest amount of sputum and occasionally sees some blood. He has noted that his lower extremities have been progressively more edematous.

Laboratory: Data includes a chest CT scan which shows a cavitary lesion of the right upper lobe about 6 cm in diameter, moderately thick-walled in character, with cavitary center; highly suggestive of carcinoma. The remainder of the CT scan is unremarkable save for a kidney cyst.

The patients laboratory data show evidence of leukocytosis, significantly elevated D Dimer, mild decrease in albumin, mild elevation in alkaline phosphatase. Hemoglobin is unremarkable. The patient’s C-reactive protein is 23.8, suggesting a dramatic inflammatory process.

Physical Examination:

General: The patient is a somewhat distant gentleman, lightly confused, with some problems with short-term memory. He wife reports that his memory is much worse than he will admit.

Vital Signs: The patient’s pulse is 100, blood pressure is 150/70, respiratory rate 16, oxygen saturation 95%, on room air.

HEENT: No acute pathology; pupils are equal and reactive to light

Neck: Supple, without thyromegaly or jugular venous distention

Chest: Resonant, quiet, and clear

Cardiac: Tones are distant, without murmur or gallop

Abdomen: Round and soft, bowel sounds are active

Extremities: There is trace swelling over the right lower extremity, and 2+ swelling of the left lower extremity.

Neurologic: The patient is somewhat confused but has no focal neurologic defects

Impression: 1. Large lesion of the patient’s upper right lobe, most likely carcinoma. 2. Weight loss, probably related to malignancy. 3. Confusion, probable brain metastasis 4. Swollen left leg 5. Bilateral knee pain Plan: First, the patient needs to be placed in respiratory isolation with acid fasts obtained and category obtained. If the patient does not have evidence of tuberculous organisms in his sputum, a bronchospastic evaluation might be reasonable. The patient is scheduled for a CAT scan of the brain to evaluate the level of brain metastasis.

Alex assigned codes: C34.11, M79.605, M25.569. Are these codes correct; why or why not? If incorrect, what specific code(s) would you assign? What code(s) if any are missing and need to be added?

Answer 1

All are correct - c34.11 for right lobe lung carcinoma

M79.605- left leg pain

M25.569 - knee pain