Present labs/diagnostic tests: No lab or diagnostic tests available. ASSESSMENT:Patient is a 36-year-old female with a history of hypertension, depression, insomnia, hypothyroidism, hyperlipidemia gastric ulcer, GERD and diverticulitis. Physical examination elicits hypoactive bowel sound, hyperresonance to percussion. Patient complained of pain 6/10 upon palpation of left lower quadrant of the abdomen. Patient’s abdomen is hard and tender. Shehas not had any bowel movement for the past 4 days and has difficulties pass gas.Differential Diagnosis:1.Large Bowel Obstruction- K56.6002.Abdominal Hernia- K46.93.Appendicitis- K35.804.Diverticulitis- K57.80
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Page 6of 6Final Diagnosis w/ ICD9 code and highlight data that support decision:1.Large Bowel Obstruction- K56.600. Patient complaint of nausea, abdominal pain, and constipation is consistent with large bowel obstruction. Patient inability to move her bowel may be as a result of blockage of large bowel that is preventing food and gas from passing through. Physical examination findings of hypoactive bowel sounds, hyperresonace, tendered abdomen, pain at left lower quadrant, and bloatedness/swelling of patient abdomen are indicative of obstruction. Chronic Diagnosis:Essential (primary) hypertension- I10. (Uncontrolled) Major depressive disorder, single episode, unspecified- F32.9 (Controlled) Insomnia, unspecified- G47.00 (Controlled) Hypothyroidism, unspecified- E03.9 (Controlled)Hyperlipidemia unspecified- E78.5 (Uncontrolled) Gastric ulcer, unspecified without hemorrhage – K25.9 (Controlled) Gastro-esophageal reflux disease without esophagitis- K21.9 (Controlled) Diverticulitis- K57.80 (Controlled) PLAN:
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