Get Answer: Outpatient Case Patient Question Guide

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Original Question

Outpatient Case 4 – Patient Name: Marvin Smalls The patient Marvin Smalls is seen due to complaint of abdominal pain. Mr. Smalls is 36 years old. Admitting diagnosis: Abdominal pain History: Abdominal pain and rectal bleeding for the past week. History: Patient has a past history of hypertension and hyperlipidemia. Previous surgery: includes previous pilonidal cystectomy. Current medications: Sectral 400 daily, Dyazide 1 b.i.d., and Wytensin 4 mg b.i.d. Allergies: Patient has no allergies Physical exam: Reveals an obese, short male in no acute distress. Vital signs: Stable. HEENT: Clear. Neck: Supple. Chest: Clear. Heart: Regular rate and rhythm. Abdomen: Obese without masses or tenderness. Rectal: Not repeated. Bones, joints, extremities: Reveals no cyanosis, clubbing, or edema. CT scan report: CT abdomen was performed with contrast and compared to the previous ultrasounds. The liver lesion described before is not seen. There is noted interposition of fat between the liver and the diaphragm anteriorly. The pancreas is well seen and is normal, and the spleen is normal. Both kidneys are well demonstrated and show no abnormalities. Operative Report Preop diagnosis: Abdominal Pain Postop diagnosis: Grade I reflux esophagitis, small hiatal hernia, internal hemorrhoids Procedure: EGD and flexible fiberoptic proctosigmoidoscopy. Preoperative note: This 36-year-old male presented with abdominal pain symptoms and reflux esophagitis symptomatology. He has continued to have some difficulty on medical management and has complained of some occasional blood per rectum. He has had an upper GI, which reveals hiatus hernia, and a barium enema, which was considered normal. He is brought to the surgery suite for EGD and flexible fiberoptic proctosigmoidoscopy. Procedure: The patient was given preoperative medication after which he then gargled Dyclone and then easily swallowed the Olympus fiberoptic gastroscope. The esophagus was noted to be mildly inflamed, consistent with a Grade I esophagitis. There were no ulcerations or tumor masses. There was no bleeding. There was a small hiatus hernia present with the GE junction at about 35 cm from the incisors. The gastric mucosa was all normal. The scope was passed through the pylorus into the first and second portions of the duodenum, where some minimal duodenitis changes were noted. No biopsies were obtained. No ulcerations were seen, no masses, etc. The scope was withdrawn, suctioning away insufflated air. The patient was then turned, and a digital-rectal examination was carried out, which was normal. The Olympus fiberoptic colonoscope was utilized and passed through the anus, rectum, and sigmoid colon under direct visualization. To approximately 60 cm, the splenic flexure was not reached. No abnormalities were noted. The scope was withdrawn, carefully inspecting the entire mucosa, and once again no lesions were identified. I believe the patient’s bleeding is attributable to internal hemorrhoids. The patient tolerated these procedures well and was returned to the recovery room for a period of observation. D. McCloud, M. D. Codes Assigned: K62.5, K44.9 43237, 45331-59 Are these the correct and complete listing of needed ICD-10-CM diagnoses codes per the clinical documentation? Are these the correct CPT codes?

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