OUTPATIENT ICD-9 AND ICD-10-CM CODING

Medical Specialty: Gastroenterology

Vomiting and abdominal pain

Description:

A 3 year-old male brought in by his mother with concerns about his eating - a very particular eater, not eating very much in general.

SUBJECTIVE:

This 3 year-old male is brought by his mother with concerns about his eating. He has become a very particular eater, and not eating very much in general. However, her primary concern was he was vomiting sometimes after particular foods. They had noted that when he would eat raw carrots, within 5 to 10 minutes he would complain that his stomach hurt and then vomit. After this occurred several times, they stopped giving him carrots. Last week, he ate some celery and the same thing happened. They had not given him any of that since. He eats other foods without any apparent pain or vomiting. Bowel movements are normal. He does have a history of reactive airway disease, intermittently. He is not diagnosed with intrinsic asthma at this time and takes no medication regularly.

CURRENT MEDICATIONS:

He is on no medications.

ALLERGIES:

He has no known medicine allergies.

OBJECTIVE:

Vital Signs:

Weight: 31.5 pounds, which is an increase of 2.5 pounds since May. Temperature is 97.1. He certainly appears in no distress. He is quite interested in looking at his books.

Neck:

Supple without adenopathy.

Lungs:

Clear.

Cardiac:

Regular rate and rhythm without murmurs.

Abdomen:

Soft without organomegaly, masses, or tenderness.

ASSESSMENT:

Report of vomiting and abdominal pain after eating raw carrots and celery. Etiology of this is unknown.

PLAN:

I talked with mother about this. Certainly, it does not suggest any kind of an allergic reaction, nor obstruction. At this time, they will simply avoid those foods. In the future, they may certainly try those again and see how he tolerates those. I did encourage a wide variety of fruits and vegetables in his diet as a general principle. If worsening symptoms, she is welcome to contact me again for reevaluation.

  • 787.01, 789.00; R11.12, R10.9
  • 787.03, 789.05; R11.11, R10.33
  • 787.04, 789.07; R11.14, R10.84
  • 787.03, 789.06; R11.10, R10.13

Answer

Melena

Description:

Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath.

HISTORY:

Reason for ICU followup today is acute anemia secondary to upper GI bleeding with melena with dropping hemoglobin from 11 to 8, status post transfusion of 2 units PRBCs with EGD performed earlier today by Dr. X of Gastroenterology confirming diagnosis of ulcerative esophagitis, also for continuing chronic obstructive pulmonary disease exacerbation with productive cough, infection and shortness of breath. Please see dictated ICU transfer note yesterday detailing the need for emergent transfer transfusion and EGD in this patient. Over the last 24 hours, the patient has received 2 units of packed red blood cells and his hematocrit and hemoglobin have returned to their baseline of approximately 11 appropriate for hemoglobin value. He also underwent EGD earlier today with Dr. X. I have discussed the case with him at length earlier this afternoon and the patient had symptoms of ulcerative esophagitis with no active bleeding. Dr. X recommended to increase the doses of his proton pump inhibitor and to avoid NSAIDs in the future. The patient today complains that he is still having issues with shortness of breath and wheezing and productive cough, now producing yellow-brown sputum with increasing frequency, but he has had no further episodes of melena since transfer to the ICU. He is also complaining of some laryngitis and some pharyngitis, but is denying any abdominal complaints, nausea, or diarrhea.

PHYSICAL EXAMINATION

VITAL SIGNS:

Blood pressure is 100/54, heart rate 80 and temperature 98.8. Is and Os negative fluid balance of 1.4 liters in the last 24 hours.

GENERAL:

This is a somnolent 68 year-old male, who arouses to voice, wakes up, seems to have good appetite, has continuing cough. Pallor is improved.

EYES:

Conjunctivae are now pink.

ENT:

Oropharynx is clear.

CARDIOVASCULAR:

Reveals distant heart tones with regular rate and rhythm.

LUNGS:

Have coarse breath sounds with wheezes, rhonchi, and soft crackles in the bases.

ABDOMEN:

Soft and nontender with no organomegaly appreciated.

EXTREMITIES:

Showed no clubbing, cyanosis or edema. Capillary refill time is now normal in the fingertips.

NEUROLOGICAL:

Cranial nerves II through XII are grossly intact with no focal neurological deficits.

LABORATORY DATA:

Laboratories drawn at 1449 today, WBC 10, hemoglobin and hematocrit 11.5 and 33.1, and platelets 288,000. This is up from 8.6 and 24.7. Platelets are stable. Sodium is 134, potassium 4.0, chloride 101, bicarb 26, BUN 19, creatinine 1.0, glucose 73, calcium 8.4, INR 0.96, iron 13%, saturations 4%, TIBC 312, TSH 0.74, CEA elevated at 8.6, ferritin 27.5 and occult blood positive. EGD, final results pending per Dr. X's note and conversation with me earlier, ulcerative esophagitis without signs of active bleeding at this time.

IMPRESSION/PLAN

  • Melena secondary to ulcerative esophagitis. We will continue to monitor the patient overnight to ensure there is no further bleeding. If there are no further episodes of melena and hemoglobin is stable or unchanged in the morning, the patient will be transferred back to medical floor for continuing treatment of his chronic obstructive pulmonary disease exacerbation.
  • 2. Chronic obstructive pulmonary disease exacerbation. The patient is doing well, taking PO. We will continue him on his oral Omnicef and azithromycin and continuing breathing treatments. We will add guaifenesin and N-acetyl-cysteine in a hope to mobilize some of his secretions. This does appear to be improving. His white count is normalized and I am hopeful we can discharge him on oral antibiotics within the next 24 to 48 hours if there are no further complications.
  • 3. Elevated CEA. The patient will need colonoscopy on an outpatient basis. He has refused this today. We would like to encourage him to do so. Of note, the patient when he came in was on bloodless protocol, but with urging did accept the transfusion. Similarly, I am hoping that with proper counseling, the patient will consent to further examination with colonoscopy given his guaiac-positive status, elevated CEA and risk factors.
  • 4. Anemia, likely some iron deficiency superimposed on top of this given his recent bleeding, with consider iron, vitamin C, folate and B12 supplementation and discharge given his history of alcoholic malnutrition and recent gastrointestinal bleeding. Total critical care time spent today discussing the case with Dr. X, examining the patient, reviewing laboratory trends, adjusting medications and counseling the patient in excess is 35 minutes.
  • 530.20, 491.22, 795.79, 280.1; K22.10, J44.0, R76.8, D50.8
  • 530.21, 491.21, 795.81, 280.0; K22.11, J44.1, R97.0, D50.0
  • 530.82, 493.22, 795.79, 281.0; K22.8, J44.1, R76.9, D51.0
  • 530.85, 493.02, 795.89, 280.9; K22.70, J45.21, R97.8, D50.9

Answer

Viral gastroenteritis

Description:

Viral gastroenteritis. Patient complaining of the onset of nausea and vomiting after she drank lots of red wine. She denies any sore throat or cough. She states no one else at home has been ill.

HISTORY OF PRESENT ILLNESS:

Patient is a 40 year-old white female visiting with her husband complaining of the onset of nausea and vomiting approximately at 11 p.m. last night, after she states she drank "lots of red wine." She states after vomiting, she felt "fine through the night," but woke with more nausea and vomiting and diaphoresis. She states she has vomited approximately 20 times today and has also had some slight diarrhea. She denies any sore throat or cough. She states no one else at home has been ill. She has not taken anything for her symptoms.

MEDICATIONS:

Currently the patient is on fluoxetine for depression and Zyrtec for environmental allergies.

ALLERGIES:

SHE HAS NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:

The patient is married and is a nonsmoker, and lives with her husband, who is here with her.

REVIEW OF SYSTEMS

Patient denies any fever or cough. She notes no blood in her vomitus or stool. The remainder of her review of systems is discussed and all are negative.

Nursing notes were reviewed with which I agree.

PHYSICAL EXAMINATION

VITAL SIGNS:

Temp is 37.6. Other vital signs are all within normal limits.

GENERAL:

Patient is a healthy-appearing, middle-aged white female who is lying on the stretcher and appears only mildly ill.

HEENT:

Head is normocephalic and atraumatic. Pharynx shows no erythema, tonsillar edema, or exudate. NECK: No enlarged anterior or posterior cervical lymph nodes. There is no meningismus.

HEART:

Regular rate and rhythm without murmurs, rubs, or gallops.

LUNGS:

Clear without rales, rhonchi, or wheezes.

ABDOMEN:

Active bowel sounds. Soft without any focal tenderness on palpation. There are no masses, guarding, or rebound noted.

SKIN:

No rash.

EXTREMITIES:

No cyanosis, clubbing, or edema.

LABORATORY DATA:

CBC shows a white count of 12.9 with an elevation in the neutrophil count on differential. Hematocrit is 33.8, but the indices are normochromic and normocytic. BMP is remarkable for a random glucose of 147. All other values are unremarkable. LFTs are normal. Serum alcohol is less than 5.

TREATMENT:

Patient was given 2 L of normal saline wide open as well as Compazine 5 mg IV x2 doses with resolution of her nausea. She was given two capsules of Imodium with some apple juice, which she was able to keep down. The patient did feel well enough to be discharged home.

ASSESSMENT:

Viral gastroenteritis.

PLAN:

Rx for Compazine 10 mg tabs, dispense five, sig. one p.o. q.8h. p.r.n. for any recurrent nausea. She was urged to use liquids only until the nausea has gone for 12 to 24 hours with slow advancement of her diet. Imodium for any diarrhea, but no dairy products until the diarrhea has gone for at least 24 hours. If she is unimproved in the next two days, she was urged to follow up with her PCP back home.

  • 008.67; A08.39
  • 008.69; A08.39
  • 008.8; A08.4
  • 009.2; A09

Answer

Dyspepsia - EGD with dilation

Description:

EGD with dilation for dyspepsia.

INDICATION:

Dyspepsia.

PREMEDICATIONS:

See procedure nurse NCS form.

PROCEDURE:

Consent PAR conference was held. After signing the informed consent, premedications were given. The patient was placed in the left lateral decubitus position and monitored with blood pressure cuff and pulse oximeter throughout the procedure. Hurricaine spray was placed in the back of the throat. The Olympus endoscope was passed under direct visualization through the cricopharyngeus into the esophageal area. It was passed through the esophagus with identification of the EG junction and into the stomach. A portion of the stomach and the rugal folds were visualized. The scope was passed into the antral area with visualization of the pylorus. The pylorus was cannulated and the duodenal bulb and the second position of the duodenum were visualized. The scope was passed back into the stomach where the cardia, fundus, and lesser curvature were visualized in a retrograde manner. The following findings were noted:

FINDINGS:

  • The esophagus was significantly tortuous and somewhat shortened with a large hiatal hernia with the EG junction at approximately 30 cm. It was difficult to tell if there was significant narrowing in the esophagus with the significant tortuosity and the scope passing into the stomach. No resistance was noted to the endoscope.
  • The stomach was abnormal with a very large sliding type hiatal hernia.
  • The duodenum was normal.
  • A Savary wire was placed in the antrum and the scope was removed. Positioning the wire by markings, a #14 French dilator was passed without difficulty into the stomach area. There was some resistance to a #16 French dilator, although at that time it had passed to approximately 40 cm and I suspect we were through the EG junction area. This may have been curling in the hiatal hernia, I opted not to use further force to advance the dilator further.

The scope was removed and the patient tolerated the procedure well.

IMPRESSION:

Very large hiatal hernia and tortuous esophagus, probably with mild peptic stricture, dilated to #14 French. I may even have gotten the #16 French dilator through, but it was not passed all the way into the stomach area because of some resistance which I suspect was curling in the hiatal hernia.

PLAN:

I will have her follow up with my nurse practitioner in approximately 10 days. If her dyspepsia is improved, we will simply observe. If she continues to have dyspepsia, we will bring her back and attempt to re-dilate her with a #15 French dilator. She will continue Aciphex long term.

  • 553.3, 530.3; K44.9, K22.2; 43248
  • 553.1, 530.6; K42.9, K22.5; 43249
  • 553.21, 530.85; K43.2, K22.70; 43245
  • 553.9, 530.89; K46.9, K22.8; 43235

Answer

Protein-calorie malnutrition - PEG tube

Description:

Percutaneous endoscopic gastrostomy tube. Protein-calorie malnutrition. The patient was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.

PREOPERATIVE DIAGNOSIS:

Protein-calorie malnutrition.

POSTOPERATIVE DIAGNOSIS:

Protein-calorie malnutrition.

PROCEDURE PERFORMED:

Percutaneous endoscopic gastrostomy (PEG) tube.

ANESTHESIA:

Conscious sedation per Anesthesia.

SPECIMEN:

None.

COMPLICATIONS:

None.

HISTORY:

The patient is a 73 year-old male who was admitted to the hospital with some mentation changes. He was unable to sustain enough caloric intake and had markedly decreased albumin stores. After discussion with the patient and the son, they agreed to place a PEG tube for nutritional supplementation.

PROCEDURE:

After informed consent was obtained, the patient was brought to the endoscopy suite. He was placed in the supine position and was given IV sedation by the Anesthesia Department. An EGD was performed from above by Dr. X. The stomach was transilluminated and an optimal position for the PEG tube was identified using the single poke method. The skin was infiltrated with local and the needle and sheath were inserted through the abdomen into the stomach under direct visualization. The needle was removed and a guidewire was inserted through the sheath. The guidewire was grasped from above with a snare by the endoscopist. It was removed completely and the Ponsky PEG tube was secured to the guidewire.

The guidewire and PEG tube were then pulled through the mouth and esophagus and snug to the abdominal wall. There was no evidence of bleeding. Photos were taken. The Bolster was placed on the PEG site. A complete dictation for the EGD will be done separately by Dr. X. The patient tolerated the procedure well and was transferred to recovery room in stable condition. He will be started on tube feedings in 6 hours with aspiration precautions and dietary to determine his nutritional goal.

  • 263.8; E46; 43752, 43246-51
  • 262; E43; 49440
  • 263.9; E46; 43246
  • 263.1; E44.1; 43441

Answer

Crohn's disease

Description:

GI Consultation for Chrohn's disease.

PROBLEM:

Prescription evaluation for Crohn's disease.

HISTORY:

This is a 46 year-old male who is here for a refill of Imuran. He is taking it at a dose of 100 mg per day. He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years. In fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. An x-ray was performed, which showed no signs of obstruction per his report. He thinks that the inciting factor of this incident was too many grapes eaten the day before. He has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past. The patient's normal bowel pattern is loose stools and this is unchanged recently. He has not had any rectal bleeding. He asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with IV insertion. He has not had any fever, red streaking up the arm, or enlargement of lymph nodes. The tenderness has now completely resolved.

He had a colonoscopy performed in August of 2003, by Dr. S. An anastomotic stricture was found at the terminal ileum/cecum junction. Dr. S recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation. No active Crohn's disease was found during the colonoscopy.

Earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests. At that time he was taking a lot of Tylenol for migraine-type headaches. Under Dr. S's recommendation, he stopped the Imuran for one month and reduced his dose of Tylenol. Since that time his liver enzymes have normalized and he has restarted the Imuran with no problems.

He also reports heartburn that is occurring on a slightly more frequent basis than it has in the past. It used to occur once a week only, but has now increased in frequency to twice a week. He takes over-the-counter H2 blockers as needed, as well as Tums. He associates the onset of his symptoms with eating spicy Mexican food.

PAST MEDICAL HISTORY:

Reviewed and unchanged.

ALLERGIES:

No known allergies to medications.

OPERATIONS:

Unchanged.

ILLNESSES:

Crohn's disease, vitamin B12 deficiency.

MEDICATIONS:

Imuran, Nascobal, Vicodin p.r.n.

REVIEW OF SYSTEMS:

Dated 08/04/04 is reviewed and noted. Please see pertinent GI issues as discussed above. Otherwise unremarkable.

PHYSICAL EXAMINATION:

GENERAL: Pleasant male in no acute distress. Well nourished and well developed. SKIN: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length. Non-tender to palpation. No erythema or red streaking. No edema. LYMPH: No epitrochlear or axillary lymph node enlargement or tenderness on the right side.

DATA REVIEWED:

Labs from June 8th and July 19th reviewed. Liver function tests normal with AST 14 and ALT 44. WBCs were slightly low at 4.8. Hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. Hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04. These results were reviewed by Dr. S and lab results letter sent.

IMPRESSION:

  • Crohn's disease, status post terminal ileum resection, on Imuran. Intermittent symptoms of bowel obstruction. Last episode three weeks ago.
  • History of non-specific hepatitis while taking high doses of Tylenol. Now resolved.
  • Increased frequency of reflux symptoms.
  • Superficial thrombophlebitis, resolving.
  • Slightly low H&H.

PLAN:

  • We discussed Dr. S's recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms. The patient emphatically states that he does not want to consider dilation at this time. The patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits. He states understanding of this. Advised to maintain low residue diet to avoid obstructions.
  • Continue with liver panel and ABC every month per Dr. S's instructions.
  • Continue Imuran 100 mg per day.
  • Continue to minimize Tylenol use. The patient is wondering if he can take another type of medication for migraines that is not Tylenol or antiinflammatories or aspirin. Dr. S is consulted and agrees that Imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. The patient will make an appointment with his primary care provider to discuss this further.
  • Reviewed the importance of prophylactic treatment of reflux-type symptoms. Encouraged the patient to take over-the-counter H2 blockers on a daily basis to prevent symptoms from occurring. The patient will try this and if he remains symptomatic, then he will call our office and a prescription for Zantac 150 mg per day will be provided. Reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent. He does not want to undergo any type of procedure such as that at this time.
  • His thrombophlebitis appears to be resolving and does not have any alarming features present. No treatment is needed at this time. He is instructed to call our office or his PCP if he experiences any pain, red streaking or fever.
  • We will watch his CBC carefully to ensure that the H&H does not continue to drop. If it does, then he may need further evaluation with iron studies, B12 levels, or a GI evaluation.

FOLLOWUP:

Continue liver panel and ABC every month; follow up pending these results. Call our office for obstructive symptoms or continued reflux. Otherwise prescription evaluation in one year.

  • 555.1, 530.9, 459.2, 266.2; K50.10, K22.9, I87.1, E53.8
  • 555.2, 530.89, 459.81, 266.9; K50.80, K22.8, I87.2, E53.9
  • 555.9, 530.5, 457.2, 266.1; K50.90, K22.4, I89.1, E53.1
  • 555.9, 530.81, 459.89, 266.2; K50.90, K21.9, I87.8, E53.8

Answer

GI bleeding

Description:

Pediatric Gastroenterology - GI Bleeding Consult.

HISTORY OF PRESENT ILLNESS:

This is a 1 year-old male patient who was admitted on 12/23/2007 with a history of GI bleeding. He was doing well until about 2 days prior to admission and when he passes hard stools, there was bright red blood in the stool. He had one more episode that day of stool; the stool was hard with blood in it. Then, he had one episode of bleeding yesterday and again one stool today, which was soft and consistent with dark red blood in it. No history of fever, no diarrhea, no history of easy bruising or excessive bleeding from minor cut. He has been slightly fussy.

PAST MEDICAL HISTORY:

Nothing significant.

PREGNANCY DELIVERY AND NURSERY COURSE:

He was born full term without complications.

PAST SURGICAL HISTORY:

None.

SIGNIFICANT ILLNESS AND REVIEW OF SYSTEMS:

Negative for heart disease, lung disease, history of cancer, blood pressure problems, or bleeding problems.

DIET:

Regular table food, 24 ounces of regular milk. He is n.p.o. now.

TRAVEL HISTORY:

Negative.

IMMUNIZATION:

Up-to-date.

ALLERGIES:

None.

MEDICATIONS:

None, but he is on IV Zantac now.

SOCIAL HISTORY:

He lives with parents and siblings.

FAMILY HISTORY:

Nothing significant.

LABORATORY EVALUATION:

On 12/24/2007, WBC 8.4, hemoglobin 7.6, hematocrit 23.2 and platelets 314,000. Sodium 135, potassium 4.7, chloride 110, CO2 20, BUN 6 and creatinine 0.3. Albumin 3.3. AST 56 and ALT 26. CRP less than 0.3. Stool rate is still negative.

DIAGNOSTIC DATA:

CT scan of the abdomen was read as normal.

PHYSICAL EXAMINATION:

VITAL SIGNS:

Temperature 99.5 degrees Fahrenheit, pulse 142 per minute and respirations 28 per minute. Weight 9.6 kilogram.

GENERAL:

He is alert and active child in no apparent distress.

HEENT:

Atraumatic and normocephalic. Pupils are equal, round and reactive to light. Extraocular movements, conjunctivae and sclerae fair. Nasal mucosa pink and moist. Pharynx is clear.

NECK:

Supple without thyromegaly or masses.

LUNGS:

Good air entry bilaterally. No rales or wheezing.

ABDOMEN:

Soft and nondistended. Bowel sounds positive. No mass palpable.

GENITALIA:

Normal male.

RECTAL:

Deferred, but there was no perianal lesion.

MUSCULOSKELETAL:

Full range of movement. No edema. No cyanosis.

CNS:

Alert, active and playful.

IMPRESSION:

A 1 year-old male patient with history of GI bleeding. Possibilities include Meckel's diverticulum, polyp, infection and vascular malformation.

PLAN:

To proceed with Meckel scan today. If Meckel scan is negative, we will consider upper endoscopy and colonoscopy. We will start colon clean out if Meckel scan is negative. We will send his stool for C. diff toxin, culture, blood for RAST test for cow milk, soy, wheat and egg. Monitor hemoglobin.

  • 569.41; K62.6
  • 578.9; K92.5
  • 569.2; K62.4
  • 569.43; K62.81

Answer

Umbilical hernia - Repair

Description:

Umbilical hernia repair template. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia.

PREOPERATIVE DIAGNOSIS:

Umbilical hernia.

POSTOPERATIVE DIAGNOSIS:

Umbilical hernia.

PROCEDURE PERFORMED:

Repair of umbilical hernia.

ANESTHESIA:

General.

COMPLICATIONS:

None.

ESTIMATED BLOOD LOSS:

Minimal.

PROCEDURE IN DETAIL:

The patient, a 48 year-old male, was prepped and draped in the sterile fashion. An infraumbilical incision was formed and taken down to the fascia. The umbilical hernia carefully reduced back into the cavity, and the fascia was closed with interrupted vertical mattress sutures to approximate the fascia, and then the wounds were infiltrated with 0.25% Marcaine. The skin was reattached to the fascia with 2-0 Vicryls. The skin was approximated with 2-0 Vicryl subcutaneous and then 4-0 Monocryl subcuticular stitches, dressed with Steri-Strips and 4 x 4's. Patient was extubated and taken to the recovery area in stable condition.

  • 553.20; K43.9; 49560
  • 553.1; K42.9; 49585
  • 553.29; K46.9; 49565
  • 553.8; K45.8; 49570

Answer

Colon cancer screening

HISTORY AND REASON FOR CONSULTATION:

For evaluation of this patient for colon cancer screening.

HISTORY OF PRESENT ILLNESS:

Mr. A is a 53 year-old gentleman who was referred for colon cancer screening. The patient said that he occasionally gets some loose stools. Other than that, there are no other medical problems.

PAST MEDICAL HISTORY:

The patient does not have any serious medical problems at all. He denies any hypertension, diabetes, or any other problems. He does not take any medications.

PAST SURGICAL HISTORY:

Surgery for deviated nasal septum in 1996.

ALLERGIES:

No known drug allergies.

SOCIAL HISTORY:

Does not smoke, but drinks occasionally for the last five years.

FAMILY HISTORY:

There is no history of any colon cancer in the family.

REVIEW OF SYSTEMS:

Denies any significant diarrhea. Sometimes he gets some loose stools. Occasionally there is some constipation. Stools caliber has not changed. There is no blood in stool or mucus in stool. No weight loss. Appetite is good. No nausea, vomiting, or difficulty in swallowing. Has occasional heartburn.

PHYSICAL EXAMINATION:

The patient is alert and oriented x3. Vital signs: Weight is 214 pounds. Blood pressure is 111/70. Pulse is 69 per minute. Respiratory rate is 18. HEENT: Negative. Neck: Supple. There is no thyromegaly. Cardiovascular: Both heart sounds are heard. Rhythm is regular. No murmur. Lungs: Clear to percussion and auscultation. Abdomen: Soft and nontender. No masses felt. Bowel sounds are heard. Extremities: Free of any edema.

IMPRESSION:

Routine colorectal cancer screening.

RECOMMENDATIONS:

Colonoscopy. I have explained the procedure of colonoscopy with benefits and risks, in particular the risk of perforation, hemorrhage, and infection. The patient agreed for it. We will proceed with it. I also explained to the patient about conscious sedation. He agreed for conscious sedation.

  • V76.51; Z12.11
  • V76.50; Z12.10
  • V76.52; Z12.13
  • V76.89; Z12.89

Answer

Constipation

Description:

Patient complains of constipation. Has not had BM for two days.

CHIEF COMPLAINT:

Patient complains of constipation, severe at times. Has not had BM for two days. Denies chest pain. Has been ambulating well. No history suggestive of angina.

Patient was informed by Dr. ABC that he does not need sleep study as per patient.

PHYSICAL EXAMINATION:

General:

Pleasant, brighter.

Vital signs:

117/78, 12, 56.

Abdomen:

Soft, nontender. Bowel sounds normal.

ASSESSMENT AND PLAN:

  • Constipation. Milk of Magnesia 30 mL daily p.r.n., Dulcolax suppository twice a week p.r.n.

Call me if constipation not resolved by a.m., consider a Fleet enema then as discussed.

  • 564.01; K59.01
  • 564.1; K58.9
  • 564.00; K59.00
  • 564.09; K59.09

Answer