HCS 214 Week 4 Gastrointestinal System–Analyzing a Progress Note

Complete the University of Phoenix Material: Gastrointestinal System-Analyzing a Progress Note

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Gastrointestinal System – Analyzing a Progress Note

Part 1

Using the following progress note, define the highlighted terms within the chart provided. 

This patient was assessed by an Urgent Care physician.

Progress Note

40 y. o. female presents with a 3 day history of stabbing pain and cramping in the lower abdomen. Patient complains of anorexia, vomiting, and diarrhea with fever. She feels week and dehydrated. Patient notes having this before one year prior. She had a colonoscopy and endoscopy at the time and was diagnosed with diverticulitis along with GERD.

Past Medical History: Diverticulitis, GERD, Cholecystitis in 2011.

Meds: Nexium 20mg every day

Allergies: Sulfa, PCN

Assessment: Vital Signs: T 101 degrees, P 110, R 18, B/P 144/92, occult blood test negative.

GEN: Appear to be in acute distress, dehydrated, bowel sounds hyperactive x4, tenderness to left and right lower quadrant with guarding.

Impression: Acute Diverticulitis of the colon, possible gastritis

Discussed with patient and planning transfer to University Hospital for direct admission.

Bolling, CNP

*Do not forget to include the sources for your definitions.

Medical term

Definition

Sources

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Part 2

Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.

Medical term Medical code

Anorexia Z72.4 Inappropriate diet and eating habits

R63.0 Anorexia

F44.9 Dissociative disorder or reaction, unspecified

F50.00 Anorexia nervosa

Gastritis K29.70 Unspecified gastritis without mention of bleeding

K29.20 Alcoholic gastritis, without mention of bleeding

K29.81 Gastritis unspecified with bleeding

K29.40 Chronic atrophic gastritis, without mention of bleeding

Diverticulitis K92.0 Hematemesis

K57.10 Diverticulosis of small intestine without perforation or abscess without bleeding

K57.32 Diverticulitis of large intestines without perforation or abscess without bleeding

N32.3 Diverticulum of bladder

References

Centers for Medicare & Medicaid Services (23 Oct. 2014). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.” Retrieved from

https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx