Reason Consultation Concern Assignment Help: How to Answer This Question

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Original Question

Reason for Consultation: Concern for colonic ischemia Requested by: Cardiology service History of Present Illness: Dennis Soutar is a 61 y/o male admitted after an aborted aortomesenteric bypass due to aspiration on anesthesia induction. He has chronic mesenteric ischemia diagnosed about 5 years ago and is s/p SMA stent, balloon angio SMA stent, and re-stent. He developed postprandial abd pain. He has known celiac occlusion. He was stabilized and then was taken for supraceliac aorta to SMA and hep artery grafts. He underwent CT scan today for increasing WBC (30) and found to have right colon thickening concerning for ischemia. Medical History: Psoriasis, htn, hyperlipidemia, DM, PVD Social History: Former smoker, 0.5ppd for 30 years Allergy: Statins Vitals: Temperature: 98.6°F Pulse: 78 Respirations: 20 Blood Pressure: 117/90 SpO2: 98% on room air Physical Examination: Constitutional: intubated CV: RRR Chest: ventilated, breath sounds b/l Abdomen: distended, midline incision with dermabond, unable to determine if the patient is having TTP due to AMS Labs Reviewed: WBC 30.12 Hb 7.6 pit 46 BUN/Cr 29/2.2 AST/ALT1008/1889 LA 1.4 Review of Imaging Findings: CT of Abdomen/Pelvis Evolving splenic and hepatic infarction with perihepatic, perisplenic, and upper mesenteric hematoma. Findings show evidence of celiac artery occlusion given the high degree of stenosis seen on prior CT scan. Bowel wall thickening of the hepatic flexure, highly concerning for bowel ischemia. No evidence of pneumatosis or intraperitoneal free air. Large pleural effusions with associated lower lobe atelectasis. Layering hyperdense material in the right pleural effusion likely represents hematoma. Impression: 61 y/o male with acute mesenteric/colonic ischemia s/p supraceliac aorto-SMA and aorto-hep artery bypass. Increasing leukocytosis and CT scan are concerning for colonic ischemia. Celiac artery compression syndrome. Hypertension. Hyperlipidemia. Type 2 DM with peripheral vascular disease. A total of 85 minutes was spent on the care and management of this patient today including appropriate review of documentation, consultation with the care team and evaluation and counseling of the patient and his family. What is the correct evaluation and management codes

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