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M131 Module 09 Coding Assignment Worksheets

Unformatted text preview: CHAPTER 6 Diseases and Disorders of the Digestive System BASIC HEALTH RECGRE) Discharge Summaries 0 2 Discharge Summary Notes thms Author Service Author Type M Note Time , MD (none) Physician 08/18/2008 2043 08/18/2008 1514 Transcription ID Transcription Status Available August 18, 2008 RE: MR#: DOB: . ADM DATE: 08/15/2008 DIS DATE: 08/18/2008 DISCHARGE SUMMARY Dear Dr. ., . . . , .discharged with primary diagnoses of: 1. Small bowel obstruction. 2. Cystic fibrosis. Secondary diagnosis of asthma. HOSPITAL COURSE Patient was admitted on August 15th for evaluation and treatment of abdominal pain and nausea. Patient had several previous admissions with same presentation. had Gastrografin enema on August 16th and after that abdominal pain resolved. Patient had bowel movement; was able to tolerate regular diet. Most relevant test results during this hospitalization; sodium 138, potassium 4.2, glucose 122. At that time, patient was on IV fluids with D5 water, creatinine 0.94, white count of 5.8. hemoglobin 13.8. No changes in medications were made. DISCHARGE MEDICATIONS 1. Pancrecarb MS-16 5 tablets with each meal and with snacks. 2. Albuterol pm. 3. Prevacid 30 mg daily. 4. Advair Diskus twice a day. 5. Multivitamin daily. 6. Vitamin E 400 international units daily. 7. Vitamin K 5 mg 3x a week. He should follow up with primary care physician in 1-2 weeks. If you have any questions regarding this hospitalization, please do not hesitate to contact me. Sincerely, ,MD 03 H&P Notes History and Physical All notes Author Service Author Type Filed Note Time . MD (none) Physician 08/16/2008 0011 08/16/2008 0001 ADMISSION HISTORY AND PHYSICAL 19yo.’ male Admission Date/Time: 8/15/2008 11:39 PM Primary Care Provider/ Referring Physician: - x i, MD Hospital Attending Physician: l Informant: Electronic Health Record and patient PATIENT PROFILE: History Social History Narrative College student _ , lives with roommates. ls engaged and has a 1 year old daughter CHIEF COMPLAINT: Abdomen pain, nausea. No bowel movement for 2 days Patient Active Problem List Diagnoses > Date Noted - Unspecified Asthma [493.90] - INTESTINAL OBSTRUCTION [560.9] 04/28/2008 l/eal obstruction As below Gastrografin enemas used in past with success - CYSTIC FIBROSIS [277.00] 10/24/2007 Has had pseudomonas in past -on/y intermittent hospital stays for resp issues but has frequent visits for i193! obstruction generally treated with Gastrografin enemas -for resp issues on advair and albutero/ -on pancreatic enzymes Follows with HPI: Patient has been having abdomen pain the past few days, but today much worse. States has not had a bowel movement in >24 hour. Usually moves bowels several times each day. States pain has been getting progressively worse today. No vomiting but feels bloated. States has had many bowel obstructions in the past. These usually respond to gastrografin enema. Episode today very similar to other episodes that he has had. States usually takes his medications and bowels are loose. When he gets obstruction everything stops. REVIEW OF SYSTEMS: A comprehensive review of systems was negative except for: Respiratory: Negative except for dyspnea and wheezing . Gastrointestinal: Negative except for nausea , constipation and abdominal pain. History and Physical continued Prescriptions prior to admission Medication Sig - ADVAIR DISKUS lNHL twice daily - ALBUTEROL 90 inhale 1 puff by MCG/ACTUATION INHL AERO inhalation route every 4—6 hours as needed - ALBUTEROL SULFATE 2.5 MG/3 prn ML NEB SOLUTION MULTlVITAMIN ORAL daily - PANCRECARB MS—16 ORAL Stabs with meals and 5 pills with snacks take 1 capsule (30 mg) by oral route once daily before a meal 400 IU once daily 5 mg, three times per week on M, W and F - PREVACID 30 MG CAP - VITAMIN E ORAL - VITAMIN K ORAL ALLERGIES/SENSITIVITIES: Allergies Allergen Reactions - Ceclor (Cefaclor) Decreased Pulmonary function tests - Bactrim (Trimethoprim-sulfamethoxazole) Hives History Social History Main Topics - Tobacco Use: Passive doesn’t smoke, had passive exposure as a child - Alcohol Use: No . Drug Use: No - Sexually Active: Not on file Family History Problem Relation Maternal Grandfather Maternal Grandmother Paternal Grandfather Maternal Grandfather Maternal Grandmother - Diabetes - Hypertension - Hypertension . Heart Disease - Cancer-breast unknown PHYSICAL EXAM: General Appearance: Uncomfortable with pain. Alert. EXAM: Head Exam: Normal. Normocephalic, atraumatic. Disp Eye Exam: Normal external eye, conjunctiva, lids, cornea. PERL. Nose Exam: Normal external nose, mucus membranes, and septum. OroPharynx Exam: Dental hygiene adequate. Normal buccal mucosa. Normal pharynx Neck Exam: Supple, no masses or nodes. Thyroid Exam: No nodules or enlargement. .3 u DSG 00 OO Chest/Respiratory Exam: Normal chest wall and respirations. Clear to auscultation. Cardiovascular Exam: Regular rate and rhythm. St, 82, no murmur, click, gallop, or rubs. Gastrointestinal Exam: Soft, nontender. no abnormal masses or oroanomeoalv “WM O 5 M Musculoskeletal Exam: Back is straight and non—tender, full ROM of upper and lower extremities. Skin: no rash or abnormalities Neurologic Exam: Nonfocal, normal gross motor movement, tone, and coordination. No tremor. Psychiatric Exam: Alert and oriented, appropriate affect. Laboratory: Recent Labs Basename WBC HGB MCV PLT INR Recent Labs Basename Additional Comments: , SODIUM POTASSIUM CHLORIDE COZTOTAL BUN CREATININE GLUCOSE CALCIUM History and Physical continued 8/15/08 2035 8.2 14.7 90 277 53/15/08 2035 138 4.0 105 24 24 1.18 108H 9.3 I reviewed the patient’s new clinical lab test results. I reviewed the patient’s new imaging test results. X-ray show multiple air fluid levels. Patient Active Hospital Problem List: CYSTIC FIBROSIS (10/24/2007) Assessment: longstanding, complicated by gastrointestinal and respiratory chronic problems INTESTINAL OBSTRUCTION (4/28/2008) Assessment: has had multiple recurrent obstructions that have responded to gastrografin enema. Plan: surgical consult in AM. Gastrografin enema ordered. As needed pain medications. NPO and intravenous fluids. Unspecified Asthma () Assessment: lungs clear tonight and no resp complaints Plan: continue usual resp medications. , MD, FACP 08 Consult Notes Consults All notes Auflm Service Author Type Filed Note Time MD (none) Physician 08/16/2008 1312 08/16/2008 1306 Full note to follow. He usually goes through this once a year but this is 3x this year. Will have crampy pain that gets worse and doesn't pass stool or flatus. GGE then will relieve this. Feels some relief now after study. WBC normal abdomen is not distended. Transverse Rt. Sided scar w/o hernia. BS active. Question of whether these increasing episodes are CF related as felt before or indication of intermitant SBO from adhesions. Clear liquids today. See how he does clinically. ‘ 0’7 All Progress Notes continued Author Service Author Type EM Note Time RN (none) NURS- 08/16/2008 0022 08/15/2008 2300 Registered Nurse Admission Note Data: , , admitted to from Medical Center via medical transport. Action: Dr. is aware of admission. Response: Patient tolerated transfer. and Patient is stable. Author Service Author Type Filed Note Time MD (none) Physician 08/16/2008 0914 08/16/2008 0909 PROGRESS NOTE 19 year old pt with history of cystic fibrosis; asthma; multiple episodes of 880 presented for evaluation and treatment of abd pain and nausea SUBJECTIVE: Pt admits feeling better today; still has abd pain but less severe; no nausea; denies SOB; has occasional cough which is chronic; passed flatus OBJECTIVE: General Appearance: patient does not appear to be in acute distress; A&Ox3 BP 107/57 | Pulse 78 | Temp 99.1 °F (37.3 °C) | Resp 16 l Sp02 93% Temp (24hrs), Avg:98.8 °F (37.1 °C), Min:98.4 °F (36.9 °C). Max:991 °F (37.3 °C) No data found. No intake or output data in the 24 hours ending 08/16 0909 HEAD, EARS, NOSE, MOUTH, AND THROAT: Normal RESPIRATORY: Normal CARDlOVASCULAR: Normal ABDOMEN: soft; tenderness mostly over the lower abd; be active; MUSCULOSKELETAL: Normal Additional Comments: I reviewed the patient's new clinical lab test results. I reviewed the patient’s new imaging test results. Abd x-ray report is pending Patient Active Hospital Problem List: CYSTlC FIBROSIS (10/24/2007) INTESTINAL OBSTRUCTlON (4/28/2008) Assessment: recurrent 880 Plan: gastrografin enema had been used in the past with good result; ordered gastrografin enema; will start on clears if enema is successful and advance as tolerated; continue IV fluid Unspecified Asthma () No signs of exacerbation O8 All Progress Notes continued Author Service Author Type Filed Note Time MD (none) Physician 08/17/2008 0943 08/17/2008 0938 PROGRESS NOTE 19 year old pt with history of cystic fibrosis; asthma; multiple episodes of 880 presented for evaluation and treatment of abd pain and nausea SUBJECTIVE: Pt had successful gastrografin enema yesterday and felt better after it; was advanced to regular diet last night but did not take enzymes with meals; this am pt developed cramping pain after the breakfast, no nausea; no SOB or cough OBJECTIVE: General Appearance: patient does not appear to be in acute distress; A&Ox3 BP 113/68 l Pulse 70 | Temp 98.1 °F (36.7 °C) | Resp 14 l Sp02 96% Temp (24hrs), Avg:98.2 °F (36.8 °C), Min:97.8 °F (36.6 °C), Max:986 °F (37 °C) No data found. Intake/Output Summary (Last 24 hours) at 08/17 0938 Last data filed at 08/16 2200 -— @— HEAD, EARS, NOSE, MOUTH, AND THROAT: Normal RESPIRATORY: Normal CARDIOVASCULAR: Normal ABDOMEN: soft; tenderness mostly over the lower abd; BS active; MUSCULOSKELETAL: Normal Additional Comments: i reviewed the patient's new clinical lab test results. I reviewed the patient’s new imaging test results. Patient Active Hospital Problem List: CYSTlC FIBROSIS (10/24/2007) INTESTINAL OBSTRUCTION (4/28/2008) Assessment: obstipation; improved with GGE Plan: continue enzymes with each meals; added Colace scheduled; pt was tried on Miralax in the past but it caused diarrhea; Unspecified Asthma () No signs of exacerbation 09 _____________._________________——————————— All Progress Notes continued Author Service Author Type Filed Note Time , MD (none) Physician 08/18/2008 1331 08/18/2008 0923 PROGRESS NOTE ' _ 19 year old pt with history of cystic fibrosis; asthma; multiple episodes of 880 presented for evaluation and treatment of abd pain and nausea . . SUBJECTIVE: Pt admits feeling well; abd pain resolved; no nausea. Pt tolerates full liqu1d diet; no BM OBJECTIVE: ' . General Appearance: patient does not appear to be in acute distress; A&Ox3 BP 104/56 | Pulse 66 | Temp 98.1 °F (36.7 °C) | Resp 16 [ Sp02 98% Temp (24hrs), Avg:98.7 °F (37.1 °C), Min:98.1 °F (36.7 °C), Max:995 °F (37.5 °C) No data found. Intake/Output Summary (Last 24 hours) at 08/18 0923 Last data filed at 08/18 0600 -— m— HEAD, EARS, NOSE, MOUTH, AND THROAT: Normal RESPIRATORY: Normal CARDIOVASCULAR: Normal ABDOMEN: soft; no tenderness, BS active; MUSCULOSKELETAL: Normal Additional Comments: I reviewed the patient's new clinical lab test results. I reviewed the patient’s new imaging test results. Patient Active Hospital Problem List: CYSTIC FIBROSIS (10/24/2007) INTESTINAL OBSTRUCTION (4/28/2008) Assessment: obstipation; improved with GGE Plan: pt tolerated regular diet for lunch; no abd pain Unspecified Asthma () No signs of exacerbation TRANSFER / DISCHARGE PLANS : do home patient discharge took <30 min 1 0 All Progress Notes continued Author Service Author Tyge Filed Note Time ’ MD (none) Physician 08/18/2008 1107 08/18/2008 1106 Feels great now. Took > ZOOOcc yesterday. Trial of regular diet today and then probable discharge. Author Service Author Type Filed Note Time . MD (none) Physician 08/17/2008 1026 08/17/2008 1024 Pt reports some crampy abdominal pain that is mild. Not much flatus. Abdomen is soft but mild to moderate tenderness in the lower abdomen. BS veg active. Resolving[?] bowel obstruction. Consider upper 6' contrast StUdY i3 COHtinUeS to '39 in progress. All Progress Notes Progress Notes All notes Author Service Author Type Filed Note Time I RN (none) NURS- 08/18/2008 1447 0811812008 1446 Registered Nurse Discharge Note Data: ' has been discharged home at 1500 via ambulatory accompanied by Volunteer. Action: Discharge/follow—up instructions were provided to patient. Prescriptions : None. Belongings sent with patient. Equipment none . Response: Patient verbalized understanding of discharge instructions, reason for discharge, and necessary follow-up appointments. Laboratory Results Results BASIC METABOLIC PANEL (I Status: Completed mm Value Units Efig Collegeg SODIUM 138 mmol/L (none) 08/16/2008 7:25 AM POTASSIUM 4.2 mmol/L (none) 08/16/2008 7:25 AM CHLORIDE 110 mmol/L (none) 08/16/2008 7:25 AM CO2,TOTAL 23 mmol/L (none) 08/16/2008 7:25 AM ANION GAP 5 (none) L 08/16/2008 7:25 AM GLUCOSE 122 mg/dL H 08/16/2008 7:25 AM CALCIUM 8.9 mg/dL (none) 08/16/2008 7:25 AM BUN 25 mg/dL (none) 08/16/2008 7:25 AM CREATININE 0.94 mg/dL (none) 08/16/2008 7:25 AM BUN/CREAT RATIO 27 (none) H 08/16/2008 7:25 AM GFR IF AFRICAN > 60 mI/min/1.73m2 (none) 08/16/2008 7:25 AM AMERICAN GFR IF NOT AFRICAN > 60 mI/min/1.73m2 (none) 08/16/2008 7:25 AM AMERICAN CBC AND DIFFERENTIAL i Status: Completed Component Value Units flag Collected WHITE BLOOD COUNT 5.8 thou/cu mm (none) 08/16/2008 7:25 AM RED BLOOD COUNT 4.67 mil/cu mm (none) 08/16/2008 7:25 AM HEMOGLOBIN 13.8 g/dL (none) 08/16/2008 7:25 AM HEMATOCRIT 41.6 % (none) 08l16/2008 7:25 AM MCV 89 fL (none) 08/16/2008 7:25 AM MCH 29.6 pg (none) 08l16/2008 7:25 AM MCHC 33.2 % (none) 08/16/2008 7:25 AM RDW 12.8 % (none) 08/16/2008 7:25 AM PLATELET COUNT 226 thou/cu mm (none) 08/16/2008 7:25 AM MPV 9.9 fL (none) 08/16/2008 7:25 AM NEUTROPHILS _ 58.3 % (none) 08/16/2008 7:25 AM LYMPHOCYTES 21.8 % L 08/16/2008 7:25 AM MONOCYTES 18.0 % H 08/16/2008 7:25 AM“ ,. ,. 7 W____ " "'fl’EOSINUF’I-TTES 7" ‘ 1.7 "% (none) 08/16/2008 7:25AM BASOPHILS 0.2 % (none) 08/16/2008 7:25 AM ABSOLUTE 3.4 thou/cu mm (none) 08/16/2008 7:25 AM NEUTROPHILS ABSOLUTE 1.3 thou/cu mm (none) 08/16/2008 7:25 AM LYMPHOCYTES ABSOLUTE MONOCYTES 1.0 thou/cu mm H 08/16/2008 7:25 AM ABSOLUTE EOSINOPHILS 0.1 thou/cu mm (none) 08/16/2008 7:25 AM ABSOLUTE BASOPHILS 0.0 thou/cu mm (none) 08/16/2008 7:25 AM Result Summary for XR COLON WATER SOLUBLE Provider Status Result Information Status Normal GASTROGRAFIN ENEMA 8/16/08 Result Narrative CLINICAL HISTORY: fibrosis. W Abdominal pain, Final result_(8/18/2008 10:37 AM)___ Reviewed constipation. History of cystic p... (‘0 FA to Result Summary for XR COLON WATER SOLUBLE continued FINDINGS: The scout film demonstrates moderate to large amount of retained stool The bowel gas pattern is nonobstructive. The colon is evaluated in a retrograde fashion. There is filling to the level of the cecum. No focal stricture is identified. Large amount of retained stool is identified, most marked over the left colon and lower colon. Postevacuation film demonstrates a moderate amount of retained contrast, but postevacuation film otherwise unremarkable. ResunlnuMBSfion Successful Gastrografin enema with filling to the level of the cecum. No focal stricture seen. Good result on postevacuation film noted, with evacuation of the colon. ,MD Radiologist Lab and Collection XR COLON WATER SOLUBLE g( ~ on 8/16/08 - Lab and Collection Information Result History XR COLON WATER SOLUBLE I 7 , i on 8/18/08 - Order Result Historx Report ...
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