How to Answer What Codes Order Questions (Complete Guide)

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Original Question

What are the codes in order for PATIENT: LOGAN, PETER ADMITTING DIAGNOSES: Dyspnea Congestive heart failure (CHF) exacerbation Hypertension Heart murmur Inferior vena cava filter placed July 2018 secondary to lower extremity deep venous thrombosis (DVT) Hypothyroidism with TSH 9.1 Peripheral vascular disease—peripheral arterial disease DISCHARGE DIAGNOSES: Dyspnea, resolved Diastolic CHF, ejection fraction 70% Hypertension, controlled Aortic stenosis with insufficiency Catheter placed secondary to deep venous thrombosis, on Coumadin, INR in 2 on discharge Hypothyroidism Peripheral vascular disease Renal ultrasound with medical disease HISTORY: A 76-year-old male was admitted with dyspnea. He was found with diastolic CHF exacerbation. The patient was seen by Dr. Shah, vascular surgeon, who believed that he had some mild arterial insufficiency and continued anticoagulation. He wants to see him in his office as an outpatient. During admission, on and off he was having numbness in bilateral feet and hands and cyanosis that resolved by themselves with no problems. Probably Raynaud phenomenon. During the admission he also was seen by cardiologist, who diuresed the patient with no complications. He believes that the patient needs to be started on 1 mg po Bumex. Weigh every day. If the weight gain is more than 3 pounds, Bumex is to be increased by 1 mg po. The patient also was seen by Dr. Almeada, who believed that the patient can go home and continue follow-up as an outpatient. Pulmonology saw the patient as well and believed the same thing. The patient has been stable. Vital signs stable, afebrile, 98% O2 stat on room air. He was complaining of some biting itching. The daughter had taken him to the dermatologist and wants to continue follow-up with the dermatologist as an outpatient. RECOMMENDATIONS: Discharge patient home. Follow up with Dr. Yablakoff in the nursing home. DISCHARGE MEDICATIONS The patient is going home with alendronate 70 mg every week, bumetanide 1 mg twice a day if the weight gain is more than 3 pounds Diovan 80 mg once a day Levothyroxine was increased to 200 mcg every day, and check TSH in 4 weeks with Dr. Yablakoff Metolazone 2.5 mg once a day Potassium 20 mEq prn every day Warfarin 5 mg every day. Check INR every day and let Dr. Yablakoff know if the INR is more than 2.5 Medrol Dosepak as directed The outpatient care plan was discussed with the patient and his daughter. They understood, had no questions, and agreed with the plan. Keith Kappinski, MD

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