Please code all the diagnoses for the inpatient admission.
Mary is a 58-year-old white female who initially presented to her physician’s office with complaints of weakness, fatigue, and a recent, unexplained weight loss. Her lab work was positive for anemia. Her physician prescribed iron supplements and followed up with Mary a month later. Labs indicated there was not much change in the anemia, and her physician decided to do a screening colonoscopy, which showed a mass in the transverse colon. The biopsy of the mass was positive for poorly differentiated adenocarcinoma. Patient’s past medical history—arthritis of the cervical spine, and hypertension. She is postmenopausal. She was a heavy smoker in the past, but quit five years ago. The patient was admitted to this facility for definitive treatment of the colon cancer. She underwent a removal of the transverse colon. During the surgery, the physician found a suspicious lesion on her liver, which was biopsied. It was negative. The patient met with the oncologist on the fourth postoperative day and was started on a regimen of chemotherapy based on her type of tumor. See the oncologist’s report for more specific information and the plan for this course of treatment.
Plan: Patient will follow up in my office in seven days. See the oncologist in three days. Continue chemo treatment as prescribed by the oncologist.
Diagnoses: Adenocarcinoma of the transverse colon Hypertension Arthritis, cervical spine Chemotherapy
Female (doe)
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