how do i begin to code this situation

LOCATION:

Inpatient, Hospital

PATIENT:

Sandra Amada

ATTENDING PHYSICIAN:

George Orbitz, MD

The patient was admitted primarily because of uremic symptomatology, namely hyperkalemia/bradycardia and generalized weakness.

The patient was admitted because of the aforementioned symptoms. The patient was then taken to ICU (intensive care unit) for emergent hemodialysis. The patient tolerated the dialysis procedure without any problems. The patient has remained hemodynamically stable throughout this hospitalization.

Consultations during this hospitalization including the following: Dr. Elhart of cardiology and Dr. Barneswell of rehabilitation medicine.

EXAMINATION: Vital signs are stable. Blood pressure: 100/46. Heart rate: 76. Respirations: 20. Temperature: 36.68C (Celsius). Saturating 92% on room air. Normocephalic and atraumatic. Pink 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. S1 (first heart sound) and S2 (second heart sound) are distinct. No S3 (third heart sound) or S4 (fourth heart sound). Regular rate and rhythm. Abdomen: Positive bowel sounds, soft and nontender. No abdominal bruits. Both upper and lower extremities reveal arthritic changes. Pulses are fair.

DISCHARGE INSTRUCTIONS: Activity level as tolerated. Diet: Renal diabetic diet.

MEDICATIONS:

1.Lipitor 10 mg (milligram) q.d. (every day).

2.Epogen 10,000 units IV (intravenous) every hemodialysis session.

3.Glipizide 10 mg q.d.

4.Levothroid 0.88 mg q.d.

5.Procardia XL 60 mg q.d.

6.Senokot-S 1-4 tabs t.i.d. (three times a day).

FOLLOW-UP APPOINTMENT CARE:

1.The patient is to be followed up during her hemodialysis sessions in the dialysis unit.

2.The patient is to be discharged to rehabilitation medicine under the care of

Dr. Barneswell for deconditioning.

CONDITION OF DISCHARGE AS COMPARED TO CONDITION ON ADMISSION: Significantly improved.

FINAL DIAGNOSES:

1.End-stage renal disease on maintenance hemodialysis (Monday, Wednesday, and Friday), secondary to the following:

A.Hypertension.

B.Type 2 diabetes mellitus.

C.Questionable previous chronic use of nonsteroidal antiinflammatory drugs/COX-2 (cyclooxygenase-2) inhibitors.

2.Anemia due to chronic renal failure.

3.Hyperkalemia.

4.Diverticulosis; status post multiple herniorrhaphies; status post cholecystectomy.

PROCEDURES PERFORMED:

1.Hemodialysis sessions.

2.Tunneled hemodialysis central venous catheter placement per Dr. Riddle of interventional radiology on Day 2.

3.Right femoral temporary hemodialysis catheter placement per Dr. Pleasant on Day 3.

I spent a total of 50 minutes evaluating and reviewing this patient's medical record, and I spent an additional 20 minutes discussing the discharge plans with the patient.