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1) What is the ICD-10-CM first-listed diagnosis code? 2) What are the secondary diagnosis codes? (there are 5) 3) The principal CPT procedure code? (CPT’s 10004-69990) enter the CPT, otherwise enter the correct E/M CPT code CHIEF COMPLAINT: “I have been vomiting for 2 days” HPI: Annie Moris is a 38 yo pre-menopausal woman who comes into the clinic 2 days after her first cycle of chemotherapy because of nausea and vomiting that started approximately 18 hours after her chemotherapy. She was diagnosed with Stage I infiltrating ductal carcinoma of the right breast 1 month ago and underwent a lumpectomy at that time. The current plan is for her to receive 8 cycles of the revised CMF chemotherapy regimen along with radiation therapy. Revised CMF consists of cyclophosphamide 600 mg/m2 IV over 1 hour, methotrexate 40 mg/m2 IV push, and fluorouracil 600 mg/m2 IV push, all given on the same day and repeated every 21 days. Her antiemetics prior to her first cycle consisted of granisetron 2 mg and dexamethasone 12 mg po 30 min before her chemotherapy. She was given prescriptions for prochlorperazine and lorazepam to be used for breakthrough nausea and vomiting. She states she did not have the prescriptions filled because she was not expecting to have problems with nausea and vomiting. PMH: Migraine headaches x 12 years Lactose intolerance Appendectomy at age 15 FH: Maternal grandmother had breast cancer, maternal great-grandmother had uterine cancer. SH: Married. No children. Works as a journalism instructor at a local college. No alcohol or tobacco use. Physically very active. Runs 18-20 miles per week and bicycles to work. ROS: Complains of */nausea, vomiting, epigastric discomfort, headache (migraine), fatigue. Denies fever, abdominal pain, diarrhea, change in stool color(i.e. melena), GU complaints, weakness, SOB, numbness or tingling in extremities. MEDS: Proranolol LA 80 mg po daily Midrin 2 po PRN migraine Calcium carbonate 1.25 g po daily Phosphate and hydroxapatite 118 mg(purchased at the local health food store) ALLERGIES: Sulfa(hives) Dairy products(diarrhea) PE: GEN: WDWN woman in moderate distress VS: BP 110/75, P 100, RR 16, T 37C, Wt 58 kg (60.5 kg 2 days ago, Ht 67 in. SKIN: Warm, dry, decreased turgor. No rashes or petechiae. Well-healing incisions on right axilla and right breast. HEENT: PERRLA, EOMI, fundi benign, TMs intact, mucous membranes dry. NECK/LN: Thyroid NL. No adenopathy. Post-op scarring right axilla. LUNGS/THORAX: Lungs clear to auscultation. BREASTS: Post-op scarring on right. CV: RRR, no m/t/g. ABD: Soft, non-tender, no HSM, appendectomy scar. GENIT/RECT: Genital exam not done. Rectal NL, stool guaiac negative MS/EXT: No R arm edema. Pulses 3+ throughout. NEURO: No visual abnormalities, cranial nerves intact, DTRs 2+ LABS: Na 146 mEq/L K 3.1 mEq/L Cl 94 mEq/L CO2 32 mEq/L BUN 30 mg/dL SCr 1.1 mg/dL Glu 71 mg/dL T. bili 0.7 mg/dL Hgb 13.6 mg/dL Hct 43% Plt 190 WBC 3.4 PMNs 48% Bands 0% Lymphs 43% Monos 6% Eos 2% Basos 1% ASSESSMENT: Dehydration and hypokalemia secondary to chemotherapy-induced emesis vs. migraine-associated nausea and vomiting. Plan: Admit to hospital for IV fluids. Repeat labs in 4 hours. Administer antiemetic. Counsel patient on her antiemetic regimen. TOTAL TIME SPENT WITH PATIENT: 37 minutes
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