Dr. Pleasant has been the attending physician for thepatient Case 1-8 while the patient’s physician, Dr. Alanda, was outof town on a personal emergency, Dr. Pleasant is providing the lastservice to the patient because Dr. Alanda is returning this eveningfrom out of town and will assume responsibility for the patient.Report Dr. Pleasant’s service.
LOCATION Inpatient, Hospital
PATIENT Kyle Ortegard
ATTENDING PHYSICIAN: Timothy L. Pleasant, MD
The patient was seen and examined and chart reviewedthe patient appen to be hemodynamically stable, not in any form ofrespiratory 6 studs or compromise No abdominal pain today and nodyspepsia norad One of other complaints he had on admission is thatof left stalgia pain. Since we started him on empiric antibioticcoverage with IV intravenous) Claforan, this has not been botheringhim anymore, We are still awaiting ENT consultation at thistime
PHYSICAL EXAMINATION: Vital signs are stable. Bloodpressure is 143/82 Heart rate is 82. Respirations 24 Saturating 97%on room air Temperature is 36.6 (Celsius). Normocephalic,atraumatic. Pink palpebral conjunctiva, anicteric sclerae. No nasalor aural discharge. Moist tongue and buccal mucosa. No pharyngealhyperemia, congestion, or exudate neck. No JVD (jugular veindistention). No lymphadenopathy No Symmetrical chest expansion Noretractions. No rhonchi. No crackles. No wheezes. S1 (first heartsound) and S2 (second heart sound) are distinct. No S3 (third heartsound) or S4 (fourth heart sound) Regular rate and irregularrhythm. Abdomen: Positive bowel sounds. Soft, nontender obese. Bothupper and lower extremities reveal no gross deformities or edemaPulses are full and equal.
ASSESSMENT/PLAN
1. Abdominal pain. Pancreatitis, ruled out Severehypertriglyceridemia of 1410 mg/dl (milligram/deciliter). Continuelow-fat low-cholesterol diet. Continue Tricor 160 mg q.d. (everyday with meals)
2 Left ear infection, questionable. The patient hasbeen started on IV Claforan and has been clinically responsive tothat medication.
At this time, we are awaiting the ENT consultation Itis hoped the patient can be discharged by Dr. Alanda’s service andbe followed in 6 weeks for recheck of his cholesterol andtriglyceride profile.
Dr. Alanda will reassume care tomorrow
What are the service and ICD-10-CM codes?
