Question..this the dignosis codes according to me as per this report 157.9, 787.02, V58.11, but not able to find the right diagnosis code for code J1642, J1100 & J2405. I am giving the report here and just suggest me what dx can be applied on these codes.
Operative reoport:- Diagnosis: Metastatic pancreatic cancer.
-11/8/10- gemcitabine
-11/15/10- tarceva/gem
-January 17, 2011- peritoneal catheter placed
HPI:
This is a very pleasant, 55-year-old, Caucasian male with history of
prostate cancer and thrombocytopenia with Stage IV pancreatic cancer. He is here for cycle 4,week 2 of gemcitabine/Tarceva.
Patient states that he feels well since the placement of his peritoneal catheter. He states that the pain at the catheter site has now resolved. He states 5 L of fluid was taken out this Monday. He states that his appetite has improved, as well as he sleeps better.
He does complain that food doesn't taste good after he takes Tarceva. Therefore, he takes it at night.
States that he is having good bowel movements.
Denies any fevers, chills, cough, or shortness of breath.
PAST MEDICAL HISTORY:
1. History of thrombocytopenia going on for years.
2. History of prostate cancer in 1999, status post surgery.
3. Metastatic pancreatic cancer.
PAST SURGICAL HISTORY:
1. Prostate resection in April 1999 and he was told that he had a
high Gleason score.
2. Bladder sling in 2000.
3. Hernia repair in 2001.
4. Re-done of his "bullateral" sling in 2008.
5. He had a diskectomy from L4 to L5 in April 2010. He states that a
week after his surgery, he was seen by the clinic and was told that
his CSF was leaking from his back and states that he had to be in the
ICU for 4 weeks and could not move because they stated that there was
a concern that he could cut his spinal cord. He states that this was
done at Northwestern.
ALLERGIES:
Per EHR.
MEDICATIONS:
Per EHR.
SOCIAL HISTORY:
The patient is single. He is here with his godfather, Ken Buss, who is
also his power of attorney. He was a sales executive, but he states
that he was fired from his job due to his prolonged health issues.
States that he quit smoking 10 years ago and used to smoke about a
pack every 2 weeks, but currently is not smoking. Denies any drug use.
Denies alcohol. Denies any history of blood transfusions.
FAMILY HISTORY:
Father died at age 44 of a heart attack. Mother is alive at 90. The
patient has 2 brothers. No known history of cancers, blood disorders
or bleeding disorders in the family.
PHYSICAL EXAM:
VITAL SIGNS: Vital signs stable; reviewed from chart.
GENERAL: Alert and oriented x3. Normal mood and affect. Resting, in
no acute distress.
HEENT: Anicteric sclera
Nontender abdomen. Firm And Mildly distended. Positive, right-sided catheter is covered by gauze. Clear bilaterally to auscultation.
Regular rate and rhythm.
No lower extremity edema
Pathology from November 3, 2010 shows atypical cells that are present
with features highly suspicious for ductal adenocarcinoma.
RADIOLOGY:
CT of abdomen/pelvis shows:
1. A 10 mm subpleural noncalcified nodule in the right lower
lobe.
2. A 5 mm nodule in the medial portion of the left lower lobe, as
well as another one in the posterior costophrenic sulcus of the left
lower lobe.
3. Hepatic lesion 3 x 3 x 3 in the anterior subcapsular portion of
the lateral segment of the left lobe of the liver.
4. A 2 x 1.4 x 1.4 cm lesion in the subcapsular inferomedial portion
of the right lobe of the liver.
5. Spleen is mild to moderately enlarged with 10 mm hypoechoic lesion
on the portal venous phase.
6. Too adjacent small irregular cystic changes of approximately 2.7
cm x 3.1 cm in the region of the neck of the pancreas without any
other pancreatic abnormality.
7. Multiple small right celiac lymph nodes.
8. No obvious pelvic mass.
ASSESSMENT AND PLAN:
This is a 55-year-old, Caucasian male with history of prostate cancer With metastatic pancreatic cancer.
#1. Stage IV T3, N1, M1 pancreatic adenocarcinoma
-Cycle #4 week 1 of gemcitabine/Tarceva. Gemcitabine was decreased to 850 mg per metered squared for prolonged neutropenia
-patient had a rash. using clindamycin gel
-moniter for side effects of including interstitial Pneumonitis, hepatic toxicity(if LFTs go greater than 3 times the normal), and renal insufficiency.
-on Ambien 10 mg p.o. q.h.s. for insomnia.
-on Megace 800 mg p.o. q. day for decreased appetite.Use as needed.
-creon tablets for abdominal bloating.
-Compazine q.6 hours p.r.n. for nausea
-Tumor markers are decreasing. I will check on a monthly basis
-Vicodin for pain.
#2. Right lower DVT.
-on arixtra.
#3. Thrombocytopenia -
-antiplatelet antibodies negative
-Will monitor
-No indication for bone marrow evaluation at this time since he has a metastatic pancreatic cancer and the bone marrow would not change any treatment
Operative reoport:- Diagnosis: Metastatic pancreatic cancer.
-11/8/10- gemcitabine
-11/15/10- tarceva/gem
-January 17, 2011- peritoneal catheter placed
HPI:
This is a very pleasant, 55-year-old, Caucasian male with history of
prostate cancer and thrombocytopenia with Stage IV pancreatic cancer. He is here for cycle 4,week 2 of gemcitabine/Tarceva.
Patient states that he feels well since the placement of his peritoneal catheter. He states that the pain at the catheter site has now resolved. He states 5 L of fluid was taken out this Monday. He states that his appetite has improved, as well as he sleeps better.
He does complain that food doesn't taste good after he takes Tarceva. Therefore, he takes it at night.
States that he is having good bowel movements.
Denies any fevers, chills, cough, or shortness of breath.
PAST MEDICAL HISTORY:
1. History of thrombocytopenia going on for years.
2. History of prostate cancer in 1999, status post surgery.
3. Metastatic pancreatic cancer.
PAST SURGICAL HISTORY:
1. Prostate resection in April 1999 and he was told that he had a
high Gleason score.
2. Bladder sling in 2000.
3. Hernia repair in 2001.
4. Re-done of his "bullateral" sling in 2008.
5. He had a diskectomy from L4 to L5 in April 2010. He states that a
week after his surgery, he was seen by the clinic and was told that
his CSF was leaking from his back and states that he had to be in the
ICU for 4 weeks and could not move because they stated that there was
a concern that he could cut his spinal cord. He states that this was
done at Northwestern.
ALLERGIES:
Per EHR.
MEDICATIONS:
Per EHR.
SOCIAL HISTORY:
The patient is single. He is here with his godfather, Ken Buss, who is
also his power of attorney. He was a sales executive, but he states
that he was fired from his job due to his prolonged health issues.
States that he quit smoking 10 years ago and used to smoke about a
pack every 2 weeks, but currently is not smoking. Denies any drug use.
Denies alcohol. Denies any history of blood transfusions.
FAMILY HISTORY:
Father died at age 44 of a heart attack. Mother is alive at 90. The
patient has 2 brothers. No known history of cancers, blood disorders
or bleeding disorders in the family.
PHYSICAL EXAM:
VITAL SIGNS: Vital signs stable; reviewed from chart.
GENERAL: Alert and oriented x3. Normal mood and affect. Resting, in
no acute distress.
HEENT: Anicteric sclera
Nontender abdomen. Firm And Mildly distended. Positive, right-sided catheter is covered by gauze. Clear bilaterally to auscultation.
Regular rate and rhythm.
No lower extremity edema
Pathology from November 3, 2010 shows atypical cells that are present
with features highly suspicious for ductal adenocarcinoma.
RADIOLOGY:
CT of abdomen/pelvis shows:
1. A 10 mm subpleural noncalcified nodule in the right lower
lobe.
2. A 5 mm nodule in the medial portion of the left lower lobe, as
well as another one in the posterior costophrenic sulcus of the left
lower lobe.
3. Hepatic lesion 3 x 3 x 3 in the anterior subcapsular portion of
the lateral segment of the left lobe of the liver.
4. A 2 x 1.4 x 1.4 cm lesion in the subcapsular inferomedial portion
of the right lobe of the liver.
5. Spleen is mild to moderately enlarged with 10 mm hypoechoic lesion
on the portal venous phase.
6. Too adjacent small irregular cystic changes of approximately 2.7
cm x 3.1 cm in the region of the neck of the pancreas without any
other pancreatic abnormality.
7. Multiple small right celiac lymph nodes.
8. No obvious pelvic mass.
ASSESSMENT AND PLAN:
This is a 55-year-old, Caucasian male with history of prostate cancer With metastatic pancreatic cancer.
#1. Stage IV T3, N1, M1 pancreatic adenocarcinoma
-Cycle #4 week 1 of gemcitabine/Tarceva. Gemcitabine was decreased to 850 mg per metered squared for prolonged neutropenia
-patient had a rash. using clindamycin gel
-moniter for side effects of including interstitial Pneumonitis, hepatic toxicity(if LFTs go greater than 3 times the normal), and renal insufficiency.
-on Ambien 10 mg p.o. q.h.s. for insomnia.
-on Megace 800 mg p.o. q. day for decreased appetite.Use as needed.
-creon tablets for abdominal bloating.
-Compazine q.6 hours p.r.n. for nausea
-Tumor markers are decreasing. I will check on a monthly basis
-Vicodin for pain.
#2. Right lower DVT.
-on arixtra.
#3. Thrombocytopenia -
-antiplatelet antibodies negative
-Will monitor
-No indication for bone marrow evaluation at this time since he has a metastatic pancreatic cancer and the bone marrow would not change any treatment