Reason Consultation Abdominal Question & Answer Guide (With Explanation)

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Key Explanation

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Original Question

Reason for Consultation: Abdominal mass Requested by: GI service History of Present Illness: This is a 59-year-old male who was seen and examined. He is resting in bed comfortably. The patient presented to ABC Hospital for abdominal pain with nausea and vomiting. At this time, nausea and vomiting have resolved and the patient is passing flatus. The patient has a history of pancreatic mass for the past 6 years. The patient states he is to have surgery for this at XYZ Hospital. The patient currently denies nausea, vomiting, diarrhea, constipation, chest pain, shortness of breath, fever, chills. Review of Systems: A 12-point review of system is negative except for as listed in HPI. Medical History: Alcohol induced chronic pancreatitis, htn, alcohol dependence Allergies: Penicillin Social History: Tobacco dependence-10 cigarettes per day, currently drinks ½ pint of Vodka daily Family History: Non-contributory Vitals: Temperature: 97.8°F Pulse: 90 Respirations: 18 Blood Pressure: 138/80 SpO2: 96% on room air Imaging Data: CT of Abdomen and Pelvis Impression: Mass noted in the head of the pancreas. Peripancreatic inflammation, small mesenteric lymph nodes, air in the biliary tree, mild thickening of wall of the retroperitoneal, duodenal sweep with mild dilation of small bowel loop. Assessment/Plan: This is a 59-year-old male with known head of the pancreas mass unrelated to other pancreatic disease, uncertain etiology of this mass. Nausea and vomiting have resolved at this time. There is no need for emergent surgery. The patient is passing flatus. We will follow up with GI recommendations. Currently weaning himself off of ½ pint of vodka daily-alcohol dependency which is most likely responsible for this bout of pancreatitis with pancreatic insufficiency. Patient also has hypertension. what are the correct CPT codes Do not put diagnosis codes

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