LOCATION: Inpatient, Hospital PATIENT: Theresa Cords ATTENDING PHYSICIAN: Gregor
ID: 3509401 • Letter: L
Question
LOCATION: Inpatient, Hospital
PATIENT: Theresa Cords
ATTENDING PHYSICIAN: Gregory Dawson, M.D
SUBJECTIVE: The patient is doing better. She was up and around yesterday and she felt much better. Her shortness of breath has improved. She has no orthopnea But some apparent dyspnea.
REVIEW OF SYSTEMS: constitutional, ophthalmologic, otolaryngologic, cardiovascular, respiratory, GI,GU, musculoskeletal, integumentary, neurologic, psychiatric, endocrine, hematologic, immunologic, negative other than what I have mentioned.
OBJECTIVE: The patient looks good and is in no acute distress. VITALS are stable. She is afebrile. HEAD, EYES, EARS, NOSE and THROAT were examined and found to be negative. NECK supple, no JVD. The ABDOMEN is benign. EXTREMITIES: The swelling has gone down but she still has some swelling on the feet. NEUROLOGIC examination is grossly intact and nonfocal. Her WEIGHT today is 154 pounds.
LABORATORY: Basic metabolic panel: BUN 43, creatinine 1.8 glucose 122. During the day her glucose has come up to around 200. Platelet count today is 128.
ASSESSMENT: 1. Congestive heart failure. 2. Diabetes mellitus, type 2 with chronic kidney disease. 3. End-stage renal failure currently on hemodialysis. 4. Fluid overload state improving. RECOMMENDATIONS: 1.We will resume amaryl 2mg, watch her accu-cheks. 2. Follow up kidney function. 3. Increase activity and discharge.
P.S I NEED THE CPT,ICD-10 AND HCPCS CODES NOT DESCRIPTION, JUST CODE.
Explanation / Answer
Answer :- As asked in above questions the codes are-
99232, N17.9, I50.9, I35.0
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