Get Answer: Medical Codes Admission Question Guide

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Original Question

medical codes for: Admission Diagnosis: Abdominal pain with symptomatic cholelithiasis History of depression History of degenerative joint disease Final Diagnosis: Abdominal pain secondary to cholelithiasis, status postlaparoscopic cholecystectomy History of depression History of degenerative joint disease DISCHARGE INSTRUCTIONS: Medications: Keflex 500 mg one tablet four times a day for 1 week, Percocet 2.5/325 one tablet four times a day p.r.n for pain, Vicodin 5.0/500 one or two tablets p.o. q4h prn for pain. Recommended follow-up in my office in about 2 weeks’ time; also recommended to follow up with the surgeon in about 7-10 days’ time. HOSPITAL COURSE: Patient is a pleasant 39-year-old Caucasian male with a past medical history of degenerative joint disease and a history of depression. He presented to my office with a chief complaint of right upper quadrant pain. The patient had been evaluated by the ER on August 31, 2018 with a sonogram, which revealed multiple echogenic foci, consistent with stones. As the patient was not getting any better and he was symptomatic, he was admitted electively for possible cholelithiasis and evaluation of his abdominal pain for possible cholecystectomy. The patient was admitted to the surgical floor. We obtained a surgical consultation from Dr. Carter’s group. Following the surgical evaluation, the patient underwent laparoscopic cholecystectomy. The patient’s postoperative course was unremarkable. He was tolerating the pain better on pain medication. Once the patient was advanced on his diet and clinically improved and he was afebrile, he was discharged with the above discharge instructions, to be followed up on an outpatient basis.

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