What ICD 9 codes should I use for this report?
Date of Consultation
8/2/15
Reason for Consultation
A 12.5 week intrauterine pregnancy and right arm abscess positive MRSA.
History of Present Illness
A 31 year old gravida 4, para 2-0-1-2, with unknown last menstrual period presenting at 12.5 weeks dated by an 11-week ultrasound performed here at ABC Hospital on 7/26/15. The patient is being readmitted for continued IV antibiotic treatment for right arm abscess secondary to IV drug use. This abscess tested positive for MRSA during the above noted admission. The patient was recently admitted on 7/26/15 and left against medical advice on 8/1/15. She returned a day later to resume treatment. She is status post I&D of this right arm abscess on 7/26/15. The patient has been restarted on IV daptomycin per infectious disease and the plan is for 2 weeks of IV antibiotics. OB is consulted due to pregnancy. The patient denies abdominal pain, cramping, leakage of fluid or vaginal bleeding. The patient does report that she has another yeast infection secondary to antibiotics as she has experienced in the past after antibiotic use. The patient has not initiated prenatal care to date. She is contemplating termination of pregnancy.
All histories & Exam have been recorded
Diagnostic Impression
1. A 12.5 week intrauterine pregnancy
2. IV drug abuse.
3. Methicillin-resistant Staphylococcus aureus bacteremia and wound culture.
4. Yeast infection
Date of Consultation
8/2/15
Reason for Consultation
A 12.5 week intrauterine pregnancy and right arm abscess positive MRSA.
History of Present Illness
A 31 year old gravida 4, para 2-0-1-2, with unknown last menstrual period presenting at 12.5 weeks dated by an 11-week ultrasound performed here at ABC Hospital on 7/26/15. The patient is being readmitted for continued IV antibiotic treatment for right arm abscess secondary to IV drug use. This abscess tested positive for MRSA during the above noted admission. The patient was recently admitted on 7/26/15 and left against medical advice on 8/1/15. She returned a day later to resume treatment. She is status post I&D of this right arm abscess on 7/26/15. The patient has been restarted on IV daptomycin per infectious disease and the plan is for 2 weeks of IV antibiotics. OB is consulted due to pregnancy. The patient denies abdominal pain, cramping, leakage of fluid or vaginal bleeding. The patient does report that she has another yeast infection secondary to antibiotics as she has experienced in the past after antibiotic use. The patient has not initiated prenatal care to date. She is contemplating termination of pregnancy.
All histories & Exam have been recorded
Diagnostic Impression
1. A 12.5 week intrauterine pregnancy
2. IV drug abuse.
3. Methicillin-resistant Staphylococcus aureus bacteremia and wound culture.
4. Yeast infection