Author Question: 2HR GLUC H 131 Ref 64-112. Identify the portion of the medical record in which the following ... (Read 60 times)

vicotolentino · **on:** Jun 27, 2018

2HR GLUC H 131 Ref 64-112.

Identify the portion of the medical record in which the following statements would MOST likely be found.

Question 2

S: This new patient got into a fight a week ago, smacked a person and had his left third knuckle cut with a tooth. This has been red and swollen for the last couple of days. Today it is much redder and much more swollen. lt is very tender.

PAST MEDICAL HISTORY: No medical problems.
MEDICATIONS: NONE.
ALLERGIES: NONE.
O: VITAL SIGNS: As noted.
HEENT: Unremarkable.
LUNGS: Clear.
HEART: Regular rate and rhythm.
EXTREMETIES: The left knuckle over the metacarpophalangeal joint is erythematous approximately 7 cm patch with a little bit of swelling right over the joint. It is very tender to touch.
A: Cellulitis of the left hand.
P: We will put him on Cephalexin 500 two pills three times a day for 10 days.
We gave him Lortab 7.5 very 46 hours as needed for pain. He is to keep heat on this and follow up in 48 hours. If he is getting worse, he should come back sooner.
ICD-9-CM diagnosis code(s): ___________________ __
___________________ ___________________ ____________
ICD-10-CM diagnosis code(s): ___________________ __
___________________ ___________________ ____________
CPT code(s) with modifier, if applicable: ___________________ __

What will be an ideal response?

heinisk01 · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

ANS: Laboratory report

Answer to Question 2

Answers:
ICD-9-CM diagnosis code(s): _681.00, E960.0
___________________ ___________________ ____________
ICD-10-CM diagnosis code(s): L03.012, Y04.0XXA
___________________ ___________________ ____________
CPT code(s) with modifier, if applicable: 99203