Transcribed Image Text from this Question
Code factors influencing health status and contact with health services Activity 3 (16 pts) In this activity you will highlight and code all Z Codes and External Cause of Morbidity Codes. History: This is a 66-year-old male who had a coronary artery bypass graft in February. He did well He was discharged home. Sometime after that when he was home, he had two days of black stools. He mentioned it to the nurse, but I’m not sure anything was done about it. He has not had any other evidence of hematemesis, melena, or hematochezia but was feeling rather weak and fatigued. He had blood work done, which showed a hemoglobin of 57, hematocrit of 20.9, MCV of 80. Serum iron of 8.2 percent saturation. No indigestion or heartbum No abdominal pain of any kind. No past history of anemia or GI bleed Past Medical History General health has been good Allergies: None known Previous Surgeries: Coronary artery bypass graft Medications: At the time of admission include Glucotrol Lasix, potassium, and aspirin Review of Systems: Endocrine: He does have diabetes, controlled with medication Cardiovascular History of coronary artery disease with coronary artery bypass graft. No recent symptoms of chest pain or shortness of breath Respiratory No chronic cough or sputum production. GU.No dysuria, hematuria, history of stones, or infections Musculoskeletal: No arthritic complaints or muscle weakness Neuropsychiatric No syncope, seizures, weakness, paralysis, or depression Family History His mother had cardiovascular disease and diabetes mellitus No history of cancer. Social History: Exposed to second-hand smoke. Pl is low-income. Pt is DNR status, On physical examination, a well-developed, well-nourished, alert male in no acute distress. Blood pressure 146/82 Respirations 18 Heart rate 78 Skin. Good turgor and texture. Eyes: No scleral icterus Pupils are round, regular, equal, and react to light. Neck No jugular venous distention. No 9 of 1094 words ORA ype here to search carotid bruits. Thyroid is not enlarged. Trachea in the midline. Lungs are clear. No heart murmur noted. Abdomen is soft. Bowel sounds present. No masses, no tenderness. Liver and spleen are not palpably enlarged. Extremities: Good pulses Trace edema of the feet Laboratory values show severe anemia with a hemoglobin of 5.7. Hemoccult is also positive. His iron studies showed low iron and low ferritin, consistent with chronic blood loss anemia. His B12 and folate levels were normal. His SMA-12 was essentially unremarkable. Impression: 1. Anemia. Probably he is anemic post bypass and then had stress gastritis with a little bit of bleeding and has never recovered from that. No evidence of acute or active bleeding at this time. The patient is stable. Possibility of occult malignancy or active peptic ulcer disease does exist. 2. Arteriosclerotic heart disease of native vessel, stable continue with 81 mg of aspirin 3. Obese BMI 32.4 Recommendations: Admit patient as an outpatient for blood transfusion. Patient is being transfused He should have an esophagogastroduodenoscopy and colonoscopy, possible biopsy or polypectomy, which has been explained to the patient along with potential risks and complications, including bleeding, transfusion, perforation, and surgery. These tests will be scheduled for a later date
(Visited 2 times, 1 visits today)
