HCS 214 Week 4 Gastrointestinal System–Analyzing a Progress Note

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 HCS 214 Week 4 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
 

 
 

 

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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
 
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