OUTPATIENT ICD-9 AND ICD-10-CM CODING

Medical Specialty: Hematology - Oncology

Aplastic anemia

Description:

Aplastic anemia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone.

CHIEF COMPLAINT:

Aplastic anemia.

HISTORY OF PRESENT ILLNESS:

This is a very pleasant 72 year-old woman, who I have been following for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/10. She was admitted to the hospital from 07/11/10 to 07/14/10 with acute kidney injury. Her cyclosporine level was 555. It was thought that her acute kidney injury was due to cyclosporine toxicity and therefore that was held.

Overall, she tells me that now she feels quite well since leaving the hospital. She was transfused 2 units of packed red blood cells while in the hospital. Repeat CBC from 07/26/10 showed white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.

CURRENT MEDICATIONS:

Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.

ALLERGIES:

No known drug allergies.

REVIEW OF SYSTEMS:

As per the HPI, otherwise negative.

PAST MEDICAL HISTORY:

  • Hypertension.
  • GERD.
  • Osteoarthritis.
  • Status post tonsillectomy.
  • Status post hysterectomy.
  • Status post bilateral cataract surgery.
  • Esophageal stricture status post dilatation approximately four times.

SOCIAL HISTORY:

She has no tobacco use. She has rare alcohol use. She has three children and is a widow. Her husband died after they were married only eight years. She is retired.

FAMILY HISTORY:

Her sister had breast cancer.

PHYSICAL EXAM:

VIT:

Height 167 cm, weight 66 kg, blood pressure 122/70, pulse 84, and temperature is 98.9.

GEN:

She is nontoxic, noncachectic appearing.

HEAD:

Examined and normal.

EYES:

Anicteric.

ENT:

No oropharyngeal lesions.

LYMPH:

No cervical, supraclavicular, or axillary lymphadenopathy.

HEART:

Regular S1, S2; no murmurs, rubs, or gallops.

LUNGS:

Clear to auscultation bilaterally.

ABDOMEN:

Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.

EXT:

Reveal no edema.

ASSESSMENT/PLAN:

Aplastic anemia. I am going to repeat her CMP today to assess her kidney function. It is possible that I may resume the cyclosporine, but at 50% dose reduction. She was supratherapeutic when her cyclosporine level was drawn in the hospital. Her values were 555 and the trough should be 100 to 400. We will continue with monthly CBCs for now and I will see her again in one month.

  • 284.9, V58.65, V87.46; D61.9, Z79.52, Z92.25
  • 285.8, V58.67, V87.49; D64.89, Z79.4, Z92.29
  • 285.9, V58.65, V87.44; D64.9, Z79.51, Z92.240
  • 285.0; D64.3

Answer

Iron deficiency anemia

Description:

Iron deficiency anemia. She underwent a bone marrow biopsy which showed a normal cellular marrow with trilineage hematopoiesis.

CHIEF COMPLAINT:

Iron deficiency anemia.

HISTORY OF PRESENT ILLNESS:

This is a very pleasant 19 year-old woman, who was recently hospitalized with iron deficiency anemia. She was seen in consultation by Dr. X. She underwent a bone marrow biopsy on 07/21/10, which showed a normal cellular marrow with trilineage hematopoiesis. On 07/22/10, her hemoglobin was 6.5 and therefore she was transfused 2 units of packed red blood cells. Her iron levels were 5 and her percent transferrin was 2. There was no evidence of hemolysis. Of note, she had a baby 5 months ago; however she does not describe excessive bleeding at the time of birth. She currently has an IUD, so she is not menstruating. She was discharged from the hospital on iron supplements. She denies any fevers, chills, or night sweats. No lymphadenopathy. No nausea or vomiting. No change in bowel or bladder habits. She specifically denies melena or hematochezia.

CURRENT MEDICATIONS:

Iron supplements and Levaquin.

ALLERGIES:

Penicillin.

REVIEW OF SYSTEMS:

As per the HPI, otherwise negative.

PAST MEDICAL HISTORY:

She is status post birth of a baby girl 5 months ago. She is G1, P1. She is currently using an IUD for contraception.

SOCIAL HISTORY:

She has no tobacco use. She has rare alcohol use. No illicit drug use.

FAMILY HISTORY:

Her maternal grandmother had stomach cancer. There is no history of hematologic malignancies.

PHYSICAL EXAM:

GEN:

She is nontoxic, noncachectic appearing.

HEAD:

Examined and normal.

EYES:

Anicteric.

ENT:

No oropharyngeal lesions.

LYMPH:

No cervical, supraclavicular, or axillary lymphadenopathy.

HEART:

Regular S1, S2; no murmurs, rubs, or gallops.

LUNGS:

Clear to auscultation bilaterally.

ABDOMEN:

Nontender, nondistended; normal bowel sounds; no hepatosplenomegaly.

EXT:

Reveal no edema.

ASSESSMENT/PLAN:

Iron deficiency anemia. At this point, I am going to schedule her for an EGD and a colonscopy. I am also going to repeat her iron studies. She had a CBC from yesterday, which showed hemoglobin of 10.4. Her MCV was still low at 74.2 and the mean cell hemoglobin was 25.0. I would also like to check her fecal occult blood test x3. I believe with her low iron levels it is going to be very difficult for her to replace it orally. I believe she may need intravenous iron infusions. If that is case, we can arrange for her to find a doctor who can give the iron infusions. She will follow up with Dr. X.

  • 280.0; D50.0
  • 281.0; D51.0
  • 280.9; D50.9
  • 280.8; D50.8

Answer

Invasive carcinoma of left breast - Modified radical mastectomy

Description:

Invasive carcinoma of left breast. Left modified radical mastectomy.

PREOPERATIVE DIAGNOSIS:

Invasive carcinoma of left breast.

POSTOPERATIVE DIAGNOSIS:

Invasive carcinoma of left breast.

OPERATION PERFORMED:

Left modified radical mastectomy.

ANESTHESIA:

General endotracheal.

INDICATION FOR THE PROCEDURE:

The patient is a 52 year-old female who recently underwent a left breast biopsy and was found to have invasive carcinoma of the left breast. The patient was elected to have a left modified radical mastectomy, she was not interested in a partial mastectomy. She is aware of the risks and complications of surgery, and wished to proceed.

DESCRIPTION OF PROCEDURE:

The patient was taken to the operating room. She underwent general endotracheal anesthetic. The TED stockings and venous compression devices were placed on both lower extremities and they were functioning well. The patient's left anterior chest wall, neck, axilla, and left arm were prepped and draped in the usual sterile manner. The recent biopsy site was located in the upper and outer quadrant of left breast. The plain incision was marked along the skin. Tissues and the flaps were injected with 0.25% Marcaine with epinephrine solution and then a transverse elliptical incision was made in the breast of the skin to include nipple areolar complex as well as the recent biopsy site. The flaps were raised superiorly and just below the clavicle medially to the sternum, laterally towards the latissimus dorsi, rectus abdominus fascia. Following this, the breast tissue along with the pectoralis major fascia were dissected off the pectoralis major muscle. The dissection was started medially and extended laterally towards the left axilla. The breast was removed and then the axillary contents were dissected out. Left axillary vein and artery were identified and preserved as well as the lung _____. The patient had several clinically palpable lymph nodes, they were removed with the axillary dissection. Care was taken to avoid injury to any of the above mentioned neurovascular structures. After the tissues were irrigated, we made sure there were no signs of bleeding. Hemostasis had been achieved with Hemoclips. Hemovac drains x2 were then brought in and placed under the left axilla as well as in the superior and inferior breast flaps. The subcu was then approximated with interrupted 4-0 Vicryl sutures and skin with clips. The drains were sutured to the chest wall with 3-0 nylon sutures. Dressing was applied and the procedure was completed. The patient went to the recovery room in stable condition.

  • 175.9; C50.929; 19301
  • 174.9; C50.919; 19306
  • 174.1; C50.119; 19304
  • 174.4; C50.412; 19307

Answer

Colon cancer

Description:

Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.

REASON FOR CONSULTATION:

I was asked by Dr. X to see the patient in consultation for a new diagnosis of colon cancer.

HISTORY OF PRESENT ILLNESS:

The patient presented to medical attention after she noticed mild abdominal cramping in February 2007. At that time, she was pregnant and was unsure if her symptoms might have been due to the pregnancy. Unfortunately, she had miscarriage at about seven weeks. She again had abdominal cramping, severe, in late March 2007. She underwent colonoscopy on 04/30/2007 by Dr. Y. Of note, she is with a family history of early colon cancers and had her first colonoscopy at age 35 and no polyps were seen at that time.

On colonoscopy, she was found to have a near-obstructing lesion at the splenic flexure. She was not able to have the scope passed past this lesion. Pathology showed a colon cancer, although I do not have a copy of that report at this time.

She had surgical resection done yesterday. The surgery was laparoscopic assisted with anastomosis. At the time of surgery, lymph nodes were palpable.

Pathology showed colon adenocarcinoma, low grade, measuring 3.8 x 1.7 cm, circumferential and invading in to the subserosal mucosa greater than 5 mm, 13 lymph nodes were negative for metastasis. There was no angiolymphatic invasion noted. Radial margin was 0.1 mm. Other margins were 5 and 6 mm. Testing for microsatellite instability is still pending.

Staging has already been done with a CT scan of the chest, abdomen, and pelvis. This showed a mass at the splenic flexure, mildly enlarged lymph nodes there, and no evidence of metastasis to liver, lungs, or other organs. The degenerative changes were noted at L5-S1. The ovaries were normal. An intrauterine device (IUD) was present in the uterus.

REVIEW OF SYSTEMS:

She has otherwise been feeling well. She has not had fevers, night sweats, or noticed lymphadenopathy. She has not had cough, shortness of breath, back pain, bone pain, blood in her stool, melena, or change in stool caliber. She was eating well up until the time of her surgery. She is up-to-date on mammography, which will be due again in June. She has no history of pulmonary, cardiac, renal, hepatic, thyroid, or central nervous system (CNS) disease.

ALLERGIES:

PENICILLIN, WHICH CAUSED HIVES WHEN SHE WAS A CHILD.

MEDICATIONS PRIOR TO ADMISSION:

None.

PAST MEDICAL HISTORY:

No significant medical problem. She has had three miscarriages, all of them at about seven weeks. She has no prior surgeries.

SOCIAL HISTORY:

She smoked cigarettes socially while in her 20s. A pack of cigarettes would last for more than a week. She does not smoke now. She has two glasses of wine per day, both red and white wine. She is married and has no children. An IUD was recently placed. She works as an esthetician.

FAMILY HISTORY:

Father died of stage IV colon cancer at age 45. This occurred when the patient was young and she is not sure of the rest of the paternal family history. She does believe that aunts and uncles on that side may have died early. Her brother died of pancreas cancer at age 44. Another brother is aged 52 and he had polyps on colonoscopy a couple of years ago. Otherwise, he has no medical problem. Mother is aged 82 and healthy. She was recently diagnosed with hemochromatosis.

PHYSICAL EXAMINATION:

GENERAL:

She is in no acute distress.

VITAL SIGNS:

The patient is afebrile with a pulse of 78, respirations 16, blood pressure 124/70, and pulse oximetry is 93% on 3 L of oxygen by nasal cannula.

SKIN:

Warm and dry. She has no jaundice.

LYMPHATICS:

No cervical or supraclavicular lymph nodes are palpable.

LUNGS:

There is no respiratory distress.

CARDIAC:

Regular rate.

ABDOMEN:

Soft and mildly tender. Dressings are clean and dry.

EXTREMITIES:

No peripheral edema is noted. Sequential compression devices (SCDs) are in place.

LABORATORY DATA:

White blood count of 11.7, hemoglobin 12.8, hematocrit 37.8, platelets 408, differential shows left shift, MCV is 99.6. Sodium is 136, potassium 4.1, bicarb 25, chloride 104, BUN 5, creatinine 0.7, and glucose is 133. Calcium is 8.8 and magnesium is 1.8.

IMPRESSION AND PLAN:

Newly diagnosed stage II colon cancer, with a stage T3c, N0, M0 colon cancer, grade 1. She does not have high-risk factors such as high grade or angiolymphatic invasion, and adequate number of lymph nodes were sampled. Although, the tumor was near obstructing, she was not having symptoms and in fact was having normal bowel movements.

A lengthy discussion was held with the patient regarding her diagnosis and prognosis. Firstly, she has a good prognosis for being cured without adjuvant therapy. I would consider her borderline for chemotherapy given her young age. Referring to the database that had been online, she has a 13% chance of relapse in the next five years, and with aggressive chemotherapy (X-linked agammaglobulinemia (XLA) platinum-based), this would be reduced to an 8% risk of relapse with a 5% benefit. Chemotherapy with 5-FU based regimen would have a smaller benefit of around 2.5%.

Plan was made to allow her to recuperate and then meet with her and her husband to discuss the pros and cons of adjuvant chemotherapy including what regimen she could consider including the side effects. We did not review all that information today.

She has a family history of early colon cancer. Her mother will be visiting in the weekend and plan is to obtain the rest of the paternal family history if we can. Tumor is being tested for microsatellite instability and we will discuss this when those results are available. She has one sibling and he is up-to-date on colonoscopy. She does report multiple tubes of blood were drawn prior to her admission. I will check with Dr. Y's office whether she has had a CEA and liver-associated enzymes assessed. If not, those can be drawn tomorrow.

  • 153.8, V45.89, V16.8; C18.8, Z97.8, Z80.8
  • 153.7, V45.3, V16.0; C18.5, Z98.0, Z80.0
  • 153.0; C18.3
  • 153.2, V26.51, V16.9; C18.6, Z98.51, Z80.9

Answer

Disseminated intravascular coagulation

Description:

Disseminated intravascular coagulation and Streptococcal pneumonia with sepsis. Patient presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation.

DIAGNOSES:

  • Disseminated intravascular coagulation.
  • Streptococcal pneumonia with sepsis.

CHIEF COMPLAINT:

Unobtainable as the patient is intubated for respiratory failure.

CURRENT HISTORY OF PRESENT ILLNESS:

This is a 20 year-old female who presented with symptoms of pneumonia and developed rapid sepsis and respiratory failure requiring intubation. At this time, she is being treated aggressively with mechanical ventilation and other supportive measures and has developed disseminated intravascular coagulation with prolonged partial thromboplastin time, prothrombin time, low fibrinogen, and elevated D-dimer. At this time, I am being consulted for further evaluation and recommendations for treatment. The nurses report that she has actually improved clinically over the last 24 hours. Bleeding has been a problem; however, it seems to have been abrogated at this time with factor replacement as well as platelet infusion. There is no prior history of coagulopathy.

PAST MEDICAL HISTORY:

Otherwise nondescript as is the past surgical history.

SOCIAL HISTORY:

There were possible illicit drugs. Her family is present, and I have discussed her case with her mother and sister.

FAMILY HISTORY:

Otherwise noncontributory.

REVIEW OF SYSTEMS:

Not otherwise pertinent.

PHYSICAL EXAMINATION:

GENERAL:

She is a sedated, young female in no acute distress, lying in bed intubated.

VITAL SIGNS:

She has a rate of 67, blood pressure of 100/60, and the respiratory rate per the ventilator approximately 14 to 16.

HEENT:

Her sclerae showed conjunctival hemorrhage. There are no petechiae. Her nasal vestibules are clear. Oropharynx has ET tube in place. NECK: No jugular venous pressure distention. CHEST: Coarse breath sounds bilaterally. HEART: Regular rate and rhythm. ABDOMEN: Soft and nontender with good bowel sounds. There was some oozing around the site of her central line. EXTREMITIES: No clubbing, cyanosis, or edema. There is no evidence of compromise arterial blood flow at the digits or of her hands or feet. LABORATORY STUDIES: The DIC parameters with a platelet count of approximately 50,000, INR of 2.4, normal PTT at this time, fibrinogen of 200, and a D-dimer of 13. IMPRESSION/PLAN: At this time is disseminated intravascular coagulation from sepsis from pneumococcal disease. My recommendation for the patient is to continue factor replacement as you are. It seems that her clinical course is reversing and simple factor replacement is probably is the best measure at this time. There is no indication at this point for Xigris. However, if her coagulopathy does not resolve within the next 24 hours and continue to improve with an elevated fibrinogen, normalization of her coagulation times, I would consider low-dose continuous infusion heparin for abrogation of consumption of coagulation routines and continued supportive infusions. I will repeat her laboratory studies in the morning and give more recommendations at that time.

  • 286.59, 038.42, 995.91, 518.84; D68.318, A41.51, J96.00
  • 286.6, 038.19, 995.91, 518.82; D65, A41.1, J80
  • 286.6, 038.2, 995.91, 518.81; D65, A40.3, J96.90
  • 286.7, 038.10, 995.91, 518.81; D68.4, A41.2, J96.00

Answer

Mesothelioma

Description:

A woman with end-stage peritoneal mesothelioma with multiple bowel perforations.

The Pain Service was asked to see Ms. A, who is a 28 year-old woman with end-stage peritoneal mesothelioma with multiple bowel perforations. She is n.p.o. and is status post pleurodesis with persistent abdominal pain.

The patient's home regimen includes Duragesic patch at 125 mcg every 3 days. She is currently on a Dilaudid PCA of 1 mg every 10 minutes lockout, Dilaudid boluses 2 mg q.3 h. p.r.n., Ativan 2 mg q.4 h., Tylenol per rectum. The patient was offered multiple procedures to help with her abdominal pain including a thoracic epidural placement for sympathetic block for pain control and a celiac plexuses/neurolytic block. The patient's family and she will continue to think about these pain procedures and let us know if they are interested in either. For the moment, we will not make any further recommendations on her current medical management. We did ask Dr. X, a psychiatrist, who works for the Pain Service to come in and see Ms. A as anxiety is a large component of her suffering at this time.

  • 158.8, 569.83; C45.1, K63.1
  • 158.0, 569.71; C48.0, K91.850
  • 158.8, 569.82; C48.8, K63.3
  • 158.9, 569.85; C48.2, K55.21

Answer

Cholangiocarcinoma

Description:

Newly diagnosed cholangiocarcinoma. The patient is noted to have an increase in her liver function tests on routine blood work. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis.

REASON FOR CONSULTATION:

Newly diagnosed cholangiocarcinoma.

HISTORY OF PRESENT ILLNESS:

The patient is a very pleasant 77 year-old female who is noted to have an increase in her liver function tests on routine blood work in December 2009. Ultrasound of the abdomen showed gallbladder sludge and gallbladder findings consistent with adenomyomatosis. Common bile duct was noted to be 10 mm in size on that ultrasound. She then underwent a CT scan of the abdomen in July 2010, which showed intrahepatic ductal dilatation with the common bile duct size being 12.7 mm. She then underwent an MRI MRCP, which was notable for stricture of the distal common bile duct. She was then referred to gastroenterology and underwent an ERCP. On August 24, 2010, she underwent the endoscopic retrograde cholangiopancreatography. She was noted to have a stricturing mass of the mid-to-proximal common bile duct consistent with cholangiocarcinoma. A temporary biliary stent was placed across the biliary stricture. Blood work was obtained during the hospitalization. She was also noted to have an elevated CA99. She comes in to clinic today for initial Medical Oncology consultation. After she sees me this morning, she has a follow-up consultation with a surgeon.

PAST MEDICAL HISTORY: Significant for hypertension and hyperlipidemia. In July, she had eye surgery on her left eye for a muscle repair. Other surgeries include left ankle surgery for a fractured ankle in 2000.

CURRENT MEDICATIONS:

Diovan 80/12.5 mg daily, Lipitor 10 mg daily, Lutein 20 mg daily, folic acid 0.8 mg daily and multivitamin daily.

ALLERGIES:

No known drug allergies.

FAMILY HISTORY:

Notable for heart disease. She had three brothers that died of complications from open heart surgery. Her parents and brothers all had hypertension. Her younger brother died at the age of 18 of infection from a butcher's shop. He was cutting Argentinean beef and contracted an infection and died within 24 hours. She has one brother that is living who has angina and a sister who is 84 with dementia. She has two adult sons who are in good health.

SOCIAL HISTORY:

The patient has been married to her second husband for the past ten years. Her first husband died in 1995. She does not have a smoking history and does not drink alcohol.

REVIEW OF SYSTEMS:

The patient reports a change in her bowels ever since she had the stent placed. She has noted some weight loss, but she notes that that is due to not eating very well. She has had some mild fatigue, but prior to her diagnosis she had absolutely no symptoms. As mentioned above, she was noted to have abnormal alkaline phosphatase and total bilirubin, AST and ALT, which prompted the followup. She has had some difficulty with her vision that has improved with her recent surgical procedure. She denies any fevers, chills, night sweats. She has had loose stools. The rest of her review of systems is negative.

PHYSICAL EXAM:

VITALS:

BP: 108/60. HEART RATE: 80.

TEMP:

98.5. Weight: 75 kg.

GEN:

She is a very pleasant female, in no acute distress.

HEENT:

She has obvious strabismus of the left eye with medial deviation. Her pupils are equal, round, and reactive to light. Oropharynx is clear.

NECK:

Supple. She has no cervical or supraclavicular adenopathy.

LUNGS:

Clear to auscultation bilaterally.

CV:

Regular rate; normal S1, S2, no murmurs.

ABDOMEN:

Soft, nontender, and nondistended. No palpable masses. No hepatosplenomegaly.

EXT:

Lower extremities are without edema.

LABORATORY STUDIES:

Sodium 141, glucose 111, total bilirubin 2.3, alkaline phosphatase 941, AST 161, and ALT 220. White blood cell count 4.3, hemoglobin 11.6, hematocrit 35, and platelets 156,000. Total bilirubin from August 25, 2010 was 1.6, alkaline phosphatase 735, AST 123, ALT 184, CA99 is 109. Bile duct brushings are notable for atypical cell clusters present, highly suspicious for carcinoma.

ASSESSMENT/PLAN:

This is a very pleasant 77 year-old female who has findings suspicious for a cholangiocarcinoma. The patient was referred to our office to discuss this diagnosis. I spent greater than an hour with the patient and her husband discussing this potential diagnosis, reviewing the anatomy and answering questions. She is yet to have a surgical consultation, and we discussed the difficulty that we sometimes have with patients meeting surgical criteria to manage cholangiocarcinoma. The patient also had questions about the Medical University and possibly seeking a second opinion. She will contact our office after her surgical consultation if she needs assistance with obtaining a second opinion. We also talked about our clinical research program here. Currently, we do have a Phase II Study for advanced gallbladder carcinoma or cholangiocarcinoma for patients that are unresectable. We will go ahead and provide her with a consent form so that she can look that over and it will give her some more information about the malignancy and treatment approaches. We will schedule her for followup in three weeks. We will also schedule her for PET/CT scan for staging.

  • 156.8; C24.0
  • 156.1; C24.0
  • 156.0; C23
  • 156.8; C24.9

Answer

Sickle cell crisis

Description:

A 19 year-old known male with sickle cell anemia comes to the emergency room on his own with 3-day history of back pain.

HISTORY OF PRESENT ILLNESS:

This is a 19 year-old known male with sickle cell anemia. He comes to the emergency room on his own with 3-day history of back pain. He is on no medicines. He does live with a roommate. Appetite is decreased. No diarrhea, vomiting. Voiding well. Bowels have been regular. Denies any abdominal pain. Complains of a slight headaches, but his main concern is back ache that extends from above the lower T-spine to the lumbosacral spine. The patient is not sure of his immunizations. The patient does have sickle cell and hemoglobin is followed in the Hematology Clinic.

ALLERGIES:

THE PATIENT IS ALLERGIC TO TYLENOL WITH CODEINE, but he states he can get morphine along with Benadryl.

MEDICATIONS:

He was previously on folic acid. None at the present time.

PAST SURGICAL HISTORY:

He has had no surgeries in the past.

FAMILY HISTORY:

Positive for diabetes, hypertension and cancer.

SOCIAL HISTORY:

He denies any smoking or drug usage.

PHYSICAL EXAMINATION:

VITAL SIGNS:

On examination, the patient has a temp of 37 degrees tympanic, pulse was recorded at 37 per minute, but subsequently it was noted to be 66 per minute, respiratory rate is 24 per minute and blood pressure is 149/66, recheck blood pressure was 132/72.

GENERAL:

He is alert, speaks in full sentences, he does not appear to be in distress.

HEENT:

Normal.

NECK:

Supple.

CHEST:

Clear.

HEART:

Regular.

ABDOMEN:

Soft. He has pain over the mid to lower spine.

SKIN:

Color is normal.

EXTREMITIES:

He moves all extremities well.

NEUROLOGIC:

Age appropriate.

ER COURSE:

It was indicated to the patient that I will be drawing labs and giving him IV fluids. Also that he will get morphine and Benadryl combination. The patient was ordered a liter of NS over an hour, and was then maintained on D5 half-normal saline at 125 an hour. CBC done showed white blood cells 4300, hemoglobin 13.1 g/dL, hematocrit 39.9%, platelets 162,000, segs 65.9, lymphs 27, monos 3.4. Chemistries done were essentially normal except for a total bilirubin of 1.6 mg/dL, all of which was indirect. The patient initially received morphine and diphenhydramine at 18:40 and this was repeated again at 8 p.m. He received morphine 5 mg and Benadryl 25 mg. I subsequently spoke to Dr. X and it was decided to admit the patient.

The patient initially stated that he wanted to be observed in the ER and given pain control and fluids and wanted to go home in the morning. He stated that he has a job interview in the morning. The resident service did come to evaluate him. The resident service then spoke to Dr. X and it was decided to admit him on to the Hematology service for control of pain and IV hydration. He is to be transitioned to p.o. medications about 4 a.m. and hopefully, he can be discharged in time to make his interview tomorrow.

IMPRESSION:

Sickle cell crisis.

  • 282.61; D57.1
  • 282.5; D57.3
  • 282.62; D57.00
  • 282.69; D57.819

Answer

Immune thrombocytopenia

Description:

Patient with immune thrombocytopenia

SUBJECTIVE:

I am following the patient today for immune thrombocytopenia. Her platelets fell to 10 on 01/09/07 and shortly after learning of that result, I increased her prednisone to 60 mg a day. Repeat on 01/16/07 revealed platelets up at 43. No bleeding problems have been noted. I have spoken with her hematologist who recommends at this point we decrease her prednisone to 40 mg for 3 days and then go down to 20 mg a day. The patient had been on 20 mg every other day at least for a while, and her platelets hovered at least above 20 or so.

PHYSICAL EXAMINATION:

Vitals: As in chart. The patient is alert, pleasant, and cooperative. She is in no apparent distress. The petechial areas on her legs have resolved.

ASSESSMENT AND PLAN:

Patient with improvement of her platelet count on burst of prednisone. We will decrease her prednisone to 40 mg for 3 days, then go down to 20 mg a day. Basically thereafter, over time, I may try to sneak it back a little bit further. She is on medicines for osteoporosis including bisphosphonate and calcium with vitamin D. We will arrange to have a CBC drawn weekly.

  • 287.30, V58.65; D69.49, Z79.51
  • 287.39, V58.65; D69.3, Z79.01
  • 287.39, V58.64; D69.49, Z79.1
  • 287.31, V58.65; D69.3, Z79.52

Answer

Malignant melanoma - Wide excision of malignant melanoma

Description:

Wide excision of malignant melanoma

Preoperative Diagnosis:

Malignant melanoma of the left upper extremity

Postoperative Diagnosis:

Malignant melanoma of the left upper extremity

Operation:

Wide local excision of melanoma

Anesthesia:

General endotracheal

Estimated Blood Loss:

Minimal

Drains:

None

Complications:

None

Findings

The patient is a 62 year-old white male who underwent an excisional biopsy of a malignant melanoma 1.6 cm in diameter near the posterolateral aspect of the left upper arm.

Examination today shows a surgical scar. A margin of 1.8 cm was outlined in a radial fashion from the periphery of the scar. A full thickness excision was performed followed by undermining and primary closure.

The patient also has a small keratotic lesion on the occipital scalp for which he requested excision.

Procedure

The patient was appropriately identified and placed in the supine position where general endotracheal anesthesia was induced and maintained. The left arm was positioned across the chest and supported. Betadine preparation was performed. Sterile drapes where applied.

Methylene blue was used to create an outline after measuring a 1.7 radius around the periphery of the scar. An incision was performed with a #15 blade. The full thickness of the skin and subcutaneous tissue was excised with Bovie electrocautery. Undermining was performed with the Bovie to create flaps. The subcutaneous tissue was then closed with interrupted, inverted sutures of #2-0 Vicryl.

The skin was closed with multiple vertical mattress sutures of #3-0 nylon. Excellent closure, without tension was obtained. A sterile dressing was applied.

All counts were reported as correct.

Attention was directed to the lesion on the occipital scalp. Again, Betadine prep was provided and a very small elliptical incision was fashioned and the lesion excised. The specimen was sent to pathology.

Closure was provided with a single suture of #3-0 nylon, followed by Bacitracin ointment.

It should be noted that the melanoma specimen from the arm was labeled with silk suture, the short suture marking superior aspect and long suture marking the posterolateral aspect. This material was sent to pathology.

The patient tolerated the procedure well and at its conclusion was transported to the postoperative recovery room in satisfactory condition.

Addendum:

The pathology report documents that the surgical margins around the upper extremity lesion were clear, with no further indications of malignant melanoma. The scalp lesion was found to be a benign hyperkeratosis.

  • 172.6, 701.9; C43.62, L85.9; 11602-LT, 12032, 11420-59
  • 172.7, 701.4; C43.70, L91.0; 11402-LT, 12031, 11421-59
  • 172.6, 702.0; D03.62, L57.0; 11603-LT, 12001, 11640
  • 172.8, 702.11; C43.8, L82.0; 11602-LT, 12032, 11420-59

Answer