mchaidez
Contributor
Hello,
Need help coding the following hospital visit.
This is what I coded but not too sure if is correct:
A41.9, N39.0, B96.20, B96.89, I48.91, N17.9, E87.2, J96.00, R79.1, E11.9
**Not too sure to use A41.59 or R78.81
64-year-old male with underlying history of left pancoast adenocarinoma s/p neoajd chem and LULobectomy
hypertension, hyperlipidemia, diabetes mellitus, prostatic hypertrophy presented with SOB, fever and hypotension.
Hypotension responded to IVF, however, patient developed worsening labored breathing and required intubation
on 9/18/19. His blood cultures returned GNR, suspected urosepsis. Patient also developed atrial fibrillation with
RVR, resolved with amiodarone. He was extubated on 9/20 AM
Overnight: Extubated this AM, doing well, reports feeling better
Assessment
# Sepsis: resolving elevated lactate. Initially hypotensive in ED, improved with IVF. Possible interstitial
pneumonia on CXR
# GNR bacteremia
# E.coli UTI
# Atrial fibrillation, RVR
- Influenza negative
- BCX (9/18): GNR
- UCX (9/18): E.coli
- Cefepime (renal dosing)
- Amiodarone
# AKI: suspect ATN, also hx of DM and proteinuria, UA with proteinuria. Improved with fluid recussitation
# Metabolic acidosis: sepsis and fluid recussitation
# Acute respiratory failure: suspect secondary to sepsis, resolving
# Elevated d-dimer: suspect secondary to recent surgery and acute inflammation
- Duplex BLE negative for DVT, echo does not show evidence of RV strain
# DM with possible diabetic nephropathy
- ISS
Need help coding the following hospital visit.
This is what I coded but not too sure if is correct:
A41.9, N39.0, B96.20, B96.89, I48.91, N17.9, E87.2, J96.00, R79.1, E11.9
**Not too sure to use A41.59 or R78.81
64-year-old male with underlying history of left pancoast adenocarinoma s/p neoajd chem and LULobectomy
hypertension, hyperlipidemia, diabetes mellitus, prostatic hypertrophy presented with SOB, fever and hypotension.
Hypotension responded to IVF, however, patient developed worsening labored breathing and required intubation
on 9/18/19. His blood cultures returned GNR, suspected urosepsis. Patient also developed atrial fibrillation with
RVR, resolved with amiodarone. He was extubated on 9/20 AM
Overnight: Extubated this AM, doing well, reports feeling better
Assessment
# Sepsis: resolving elevated lactate. Initially hypotensive in ED, improved with IVF. Possible interstitial
pneumonia on CXR
# GNR bacteremia
# E.coli UTI
# Atrial fibrillation, RVR
- Influenza negative
- BCX (9/18): GNR
- UCX (9/18): E.coli
- Cefepime (renal dosing)
- Amiodarone
# AKI: suspect ATN, also hx of DM and proteinuria, UA with proteinuria. Improved with fluid recussitation
# Metabolic acidosis: sepsis and fluid recussitation
# Acute respiratory failure: suspect secondary to sepsis, resolving
# Elevated d-dimer: suspect secondary to recent surgery and acute inflammation
- Duplex BLE negative for DVT, echo does not show evidence of RV strain
# DM with possible diabetic nephropathy
- ISS