Author Question: _________ Dr. Crews is concerned about the gangrene occurring in her foot and asked me to evaluate ... (Read 66 times)

deesands · **on:** Jun 27, 2018

_________ Dr. Crews is concerned about the gangrene occurring in her foot and asked me to evaluate the situation.

Fill in the blank with correct word.

Question 2

S: This established patient comes in stating that her legs are swollen and tender to touch. She has had a little bit of shortness of breath and just has not been feeling normal. PAST MEDICAL HlSTORY: Congestive heart failure, hypertension, and gastritis. MEDICATlON: Warfarin, potassium, Lasix, Clonapam, metoprolol, Dilantin, and orneprazole. ALLERGIES: PENICILLIN.

S: This established patient comes in stating that her legs are swollen and tender to touch. She has had a little bit of shortness of breath and just has not been feeling normal. PAST MEDICAL HlSTORY: Congestive heart failure, hypertension, and gastritis. MEDICATlON: Warfarin, potassium, Lasix, Clonapam, metoprolol, Dilantin, and orneprazole. ALLERGIES: PENICILLIN.
O: VITAL SIGNS: As noted. O2 saturations 88. GENERAL: Alert and oriented. HEENT: Unremarkable. LUNGS: There are a few crackles in the lungs. HEART: Regular rate and rhythm. EXTREMITIES: There is 2+ edema. LABORATORY/DIAGNOSTIC: Normal CBC. Comprehensive panel shows a BUN that is slightly elevated, otherwise unremarkable. Her BNP is high at 442.
A: Congestive heart failure, peripheral edema
P: We will have her double up her Lasix taking 2 a day and potassium 2 per day for the next 5 days and then go back to her regular medications. If she is still having swelling problems, she is to let us know.
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?

miss.ashley · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

ANS: Consultation report

Answer to Question 2

Answers:
ICD-9-CM diagnosis code(s): 428.0, 782.3
___________________ ___________________ ____________
ICD-10-CM diagnosis code(s): I50.9, R60.0
___________________ ___________________ ____________
CPT code(s) with modifier, if applicable: 99214