Reason Consultation Abdominal Explained for Students (Easy Guide)
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Original Question
Reason for Consultation: Abdominal pain History of Present Illness: The patient is a 52 y/o male that presents with hx ETOH pancreatitis. The patient was admitted on 09-01-XX with acute on chronic ETOH pancreatitis. The patient states the pain never really went away, but over the last 2 days or so, he has had increasing pain, nausea, vomiting. He denies any diarrhea, constipation. Last bowel movement was yesterday. Positive for chills. No GI bleeding. Medical History: Chronic ETOH pancreatitis, hypertension, CAD, old MI, Alcohol dependence Surgical History: Cholecystectomy, abdominal surgery for cholangiocarcinoma. Social History: Drinks 6 cans of beer/day Family History: Negative for cancer of the GI tract. Allergies: NKDA Review of Systems: Epigastric pain radiating to left upper quadrant, right upper quadrant and bilateral back with nausea and vomiting. No GI bleeding. Last bowel movement yesterday. Medications: Subcutaneous heparin Vitals: Temperature Pulse Respirations Blood Pressure SpO2 98.5°F 68 20 120/66 98% on room air Physical Examination: GENERAL: No apparent distress. He is alert and oriented x 3, talking on the phone. HEENT: Normocephalic, facial symmetry. No icterus, no jaundice, no pallor. https://myahima.brightspace.com/content/enforced/6681-VLAB_STUDENTPROTO/PatientCaseScenarios/Inpatient_Consultation/IPC59KnochArmond… 1/2 6/6/2021 IPC59KnochArmond CARDIOVASCULAR: S1, S2 present. Regular rate and rhythm. RESPIRATIONS: Breath sounds clear to auscultation, bilaterally equal. No dyspnea. ABDOMEN: Bowel sounds quadrant x 4. Nondistended, soft. Moderate epigastric and left upper quadrant tenderness. No organomegaly. No masses palpated. EXTREMITIES: Peripheral pulses present. SKIN: Warm, dry. No cyanosis, no pallor, no jaundice. Laboratory Data: White count yesterday 11.2, today 10.4, hemoglobin 12.4, platelets 281,000. BUN 8, creatinine 0.72, potassium 4.1. Liver chemistry yesterday within normal limits. Lipase is 33. Assessment: 1. Acute on chronic ETOH pancreatitis with exocrine insufficiency. Epigastric pain with referral to pain management for recommendations due to substance abuse issues. 2. Hypertension 3. CAD, history of MI. 4. ETOH dependence, currently drinks 6 cans of beer/day. 5. Mild anemia. Plan: 1. Keep npo for now. Continue IV hydration. Will add proton pump inhibitor and pancrelipase. 2. Monitor CBC, CMP, lipase, check CRP, lipid profile, FOB. 3. Will get CT abdomen and pelvis with contrast. 4. The rest of plan will depend on the findings of above tests. What are the ICD-10-CM codes?
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