need to know the folkwing if applicabke: cpt code, modifiercode, ICD-10 CM codes, and/or HCPCS codes associated with patientscenario.
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DESIGN DAGE LAYOUT HOME INSERT -OD- Cassandra. Hospital Emergency – Word MAHUNES REVIEW VIEW DEVELOPER ADO-INS REFERENCES Gonne Jacqueline 7-X HH Module 5: Emergency Medicine – Report 25: Emergency Department Services LOCATION: Hospital Emergency Department PATIENT: Dolores Newman: age 82 PHYSICIAN: Paul Sutton, M.D. SUBJECTIVE: Complaint of multiple diarrhea stools. Greater than 10 to 15 over the last 24 hours. Weakness, dizziness, lightheadedness, and some sweats Questions some low-grade chills. She does admit to nausea. No vomiting, No documented fever at home. No chest pain or shortness of breath. Some cramping intermittent abdominal pain, lower down. Denies any joint aches or arthralgias. No recent antibiotic use. Weakness and dehydration as per HPL Decreased urine output. No frequency. Longstanding history of diarrhea. Extensive workup in the past, all negative. She had son loose stools earlier, but multiple and severe now. No recent antibiotics in the last 3 to 6 months. Colonoscopy a year ago was unremarkable other than some patchy erythema Negative for nonspecific colitis PAST MEDICAL HISTORY: Notable for diarrhea, hypertension, osteoporosis, non-insulin diabetes, chronic kidney disease, osteoarthritis, hypothyroidism MEDICATIONS: Multiple, see attached list. ALLERGIES: 1. CODEINE. 2. PENICILLIN SOCIAL HISTORY: Nonsmoker. Widowed. Lives independently. Uses a walker REVIEW OF SYSTEMS: CONSTITUTIONAL: Chills but no fover. General malaise and weakness today. PSYCHIATRIC. No depression EYES: No visual difficulties ENT. No sore throat or sinus symptoms. RESPIRATORY: No wheezing, cough, or hemoptysis. CARDIAC No chest pain, orthopnes, or PND. GI: No molens or hematochezia. No bruising or bleeding difficulties Cramping abdominal pain as per HPI. Diarrhea as per HPL GENITOURINARY. No urgency. SKINNo rashes or skin changes. No edema. JOINTS: No swelling of the joints. NEUROLOGICAL Paresthesias, numbness of the extremities HEMATOLOGICNo bruising or bloeding. No history of swelling of her lymph glands. Remainder of review of systems is otherwise negative aside from HPI. OBJECTIVE On assessment, NAD. VITAL SIGNS: Low-grade temperature 37.8 degrees, pulse 70, respiratory rate 16, blood pressure 131/64 saturations 97% HEENT: Pupils are equal and reactive to light and accommodation. No iritis or conjunctivitis External auditory canals and TMs normal. Throat: No erythema or exudate NECK No adenopathy. Trachea midine CHEST: Clear air entry HEART: Sounds are normal without murmur. ABDOMEN: Soft Liver, kidneys, and spleen are normal to palpation Bowel sounds are present. There is no guarding or rebound. EXTREMITIES: Peripheral pulses palpable. SKIN: Warm and dry. No rashes, skin changes, or adema, NEUROLOGIC EXAM: Cranial nerves 2-12 are intact. Sensory/Motor Exam intact. Power is 5 out of 5. Alert and oriented 5. There is no significant groin or axillary adenopathy COURSE IN THE EOD: Admitted to the department. I and 02 monitor. Low-grade temperature. A 3-view abdomen nonspecific gas pattern. No air fluid levels Chest x-ray no infiltrate. Urinalysis: Too numerous to count white cells. CBC white count 13, hemoglobin and platelets stable. Comprehensive metabollo panel: Slightly low sodium. Lipase 145, hemoglobin 12. platelets 180. BUN 20, creatinine 1.4. sodium 135, potassium is 3.4 glucose 148, ak pos 243. Liver panel normal IMPRESSION: 1. Diarrhea. 2. Dehydration. 3. Urinary tract infection PLAN: We will admit her because she is dehydrated, elderly, with comorbidities. IV fluids, Bowel rest. Nonspecifio gas pattern with increasing pain on her abdomen, she will require probably a CT scan for further evaluation. Morphine parentally along with some Zofran was given for nausea and pain. Further management per medicine Need the following codes if applicable: CPT Code, Modifier Code, ICD-10-CM Code, HCPCS Code +++++++++++++ ++++++ TE WORDS
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