This Year Female Explained for Students (Easy Guide)

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Original Question

This 56-year-old female was admitted for resection of an adrenal mass. The patient has had hypertension and palpitations of several years’ duration treated with Toprol under good control. Ultrasound was done in consideration of the possibility of a mass, and catecholamine studies have been normal. A 4- to 5-cm right adrenal mass was identified. Dr. White had obtained a 24-hour urinary free cortisol, ACTH, and short suppression tests, all of which confirmed the presence of Cushing’s syndrome. The patient was not diabetic. She did report weight gain, some shift in body configuration, and easy bruising of several years’ duration. The easy bruising was identified on examination in the hospital. Surgery: A 5-cm, well-circumscribed round cortical tumor was resected from the adrenal gland via an open approach. Pathology report confirmed that the tumor was benign. Allergies: No known drug allergies Medications on Discharge: Hydrocortisone, rapidly tapering dose, currently on 40 mg daily; Toprol 50 mg q. a.m.; Prevacid 30 mg q. d.; Lipitor 10 mg q. a.m.; Prempro 0.625/2.5. Physical Exam: Vital signs stable. HEENT: Sclerae and conjunctivae clear. Neck: Supple. No palpable thyroid. Lungs: Somewhat decreased breath sounds currently. There is mild splinting with deep breathing. Abdomen: Tenderness in the incision area. She has active bowel sounds at this time. Extremities: No definite bruises currently. No edema noted. Discharge Diagnosis: Right adrenal tumor with Cushing’s syndrome secondary to tumor. Plan: The patient appears to have tolerated the surgery well. She will require steroid replacement. Excess cortisol output is presumed entirely due to her tumor, and her ACTH was suppressed previously. As with exogenous steroid therapy, there will be contralateral adrenal suppression. The patient will be tapered rapidly to replacement hydrocortisone levels. We will try the remaining hydrocortisone withdrawal over the next 6 months or so, depending on her ACTH and cortisol responses. She is discharged to home with follow-up in my office in 1 week. Which of the following is the correct code set for this hospitalization

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