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HEMODIALYSIS PROGRESS REPORT The patient has been admitted to the hospital for the purpose of hemodialysis. LOCATION: Inpatient, Hospital PATIENT:...

HEMODIALYSIS PROGRESS REPORT

The patient has been admitted to the hospital for the purpose of hemodialysis.

LOCATION: Inpatient, Hospital

PATIENT: Debra Chitzan

ATTENDING PHYSICIAN: George Orbitz, M.D.

The patient is seen and examined during hemodialysis. Chart is reviewed. The patient appears to be hemodynamically stable and not in any form of respiratory distress or compromise. She is tolerating dialysis without any problems. Predialysis vital signs are stable. Blood pressure is 134/63, heart rate 57, and temperature 98.6F. She weighs 139.8 pounds. Today, we will dialyze her using her left Perm-A-Cath for a total of 3 hours using an HP-150 dialyzer and a 2.0 potassium bath. We will give her a Heparin loading dose of 2000 units and then maintenance of 1ml per hour.

At the present time, vital signs are stable. Blood pressure is 117/61, heart rate 57, and she is tolerating a blood flow rate of 350 ml per minute. Normocephalic and atraumatic. Pale palpebral conjunctivae. Anicteric sclerae. No nasal or aural discharge. Moist tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple neck. No lymphadenopathy; symmetrical chest. No retractions. Positive rhonchi. No crackles or wheezes. S1 and S2 distinct. No S3 or S4. Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. Status post below-knee amputation. Pulses are fair.

Latest labs performed 1 month ago are as follows: Sodium 136, potassium 6.4, chloride 103, CO2 16.8, BUN and creatinine 92/8.7, glucose 74, and calcium 9. Hemogram shows H&H of 11.4/33.9.

Because of diarrhea, Clostridium difficile toxin was also studied, and this turned out to be negative.

ASSESSMENT/PLAN:

1. Chronic renal failure/end-stage renal disease (on maintenance hemodialysis Tuesday, Thursday, and Saturday) secondary to the following:

A. Status post right-sided nephrectomy 7 years ago.

B. Left-sided renal artery stenosis/renal vascular hypertension.

C. Diabetes II.

The patient is tolerating dialysis without any problems. We will give her Zemplar 2.5 mcg after dialysis.

ICD-9 and CPT code this case: Answer format: ICD-9 codes first then CPT code ( Hint 7 ICD-9 and 1 CPT)

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1. HEMODIALYSIS PROGRESS REPORT The patient has been admitted to the hospital for the purpose of hemodialysis. LOCATION: Inpatient, Hospital PATIENT: Debra Chitzan ATTENDING PHYSICIAN: George Orbitz, M.D. The patient is seen and examined during hemodialysis. Chart is reviewed. The patient  appears to be hemodynamically stable and not in any form of respiratory distress or  compromise. She is tolerating dialysis without any problems. Predialysis vital signs are  stable. Blood pressure is 134/63, heart rate 57, and temperature 98.6F. She weighs  139.8 pounds. Today, we will dialyze her using her left Perm-A-Cath for a total of 3 hours  using an HP-150 dialyzer and a 2.0 potassium bath. We will give her a Heparin loading  dose of 2000 units and then maintenance of 1ml per hour. At the present time, vital signs are stable. Blood pressure is 117/61, heart rate 57, and  she is tolerating a blood flow rate of 350 ml per minute. Normocephalic and atraumatic.  Pale palpebral conjunctivae. Anicteric sclerae. No nasal or aural discharge. Moist  tongue and buccal mucosa. No pharyngeal hyperemia, congestion, or exudates. Supple  neck. No lymphadenopathy; symmetrical chest. No retractions. Positive rhonchi. No  crackles or wheezes. S1 and S2 distinct. No S3 or S4. Regular rate and rhythm.  Abdomen: Positive bowel sounds, soft and nontender. Status post below-knee  amputation. Pulses are fair. Latest labs performed 1 month ago are as follows: Sodium 136, potassium 6.4, chloride  103, CO 2  16.8, BUN and creatinine 92/8.7, glucose 74, and calcium 9. Hemogram shows  H&H of 11.4/33.9. Because of diarrhea,  Clostridium difficile  toxin was also studied, and this turned out to  be negative. ASSESSMENT/PLAN: 1.      Chronic renal failure/end-stage renal disease (on maintenance hemodialysis  Tuesday, Thursday, and Saturday) secondary to the following: A.    Status post right-sided nephrectomy 7 years ago. B.     Left-sided renal artery stenosis/renal vascular hypertension. C.     Diabetes II. The patient is tolerating dialysis without any problems. We will give her Zemplar 2.5 mcg after dialysis. ICD-9 and CPT code this case: Answer format: ICD-9 codes first then CPT code ( Hint 7 ICD-9 and 1 CPT)
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(Points: 5) 2. CLINIC PROGRESS NOTE This patient presents to the physician’s office for an examination after a C-section the previous week. LOCATION: Outpatient, Clinic PATIENT: Beth Olgia PHYSICIAN: Gary Sanchez, M.D. SUBJECTIVE: Beth came in today for a postoperative exam. She underwent a C-section last week along with a tubal ligation. She was discharged on Monday of this week and is back in for a staple removal. Her blood pressure is still up, and today it is 170/102. Dr. Naraquist has been following this. She says her blood sugars have been okay. Dr. Naraquist is following her blood sugars. CURRENT MEDICATIONS: 1. Prenatal vitamins once a day. 2. Peri-Colace 1 b.i.d. 3. Darvocet p.r.n. 4. Labetalol 600 mg q.a.m., 200 mg at 3 p.m., and 600 mg at bedtime. ALLERGIES: None OBJECTIVE: Her wound is healing okay. PLAN: The staples are removed. I told her not to do any heavy lifting over 20 pounds for the next five weeks, also no intercourse. She is to see us back again in five weeks. Code the ICD-9 and CPT codes for this case using ICD-9 CPT format style (Points: 5) 3. RENAL ULTRASOUND LOCATION: Outpatient, Hospital PATIENT: Sally Cinder PHYSICIAN: Timothy Pleasant, M.D. RADIOLOGIST: Morton Monson, M.D. EXAMINATION OF: Renal ultrasound, Complete CLINICAL SYMPTOMS: Renal failure RENAL ULTRASOUND: Clinical information states renal failure Right kidney is 9.5 ´ 5.6 ´ 4.9 cm. The size and parenchymal thickness are within normal  limits. No cystic or solid mass right kidney seen. No dilatation of calyces to suggest  obstruction of collecting system.
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