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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