I had a patient for initial hospital care. The Soap note as following:
Subjective:
Reason for admission hypotension complete heart block
Patient has a history of cancer of the breast. She developed severe headache and hence she called paramedics on the way the paramedics noted she was in complete heart block with a rate 30. In the ER she was intubated secondary to acute respiratory failure and hypotension. She is admitted to ICU. The CT scan of the head was suggestive of subdural fluid collection question CSF versus hygroma. Patient was given IV fluid challenge in ER and admitted to ICU for further care she has a significant comorbid condition of diabetes or hypertension. No fever or chills. Source of information ER records .
Assessment and Plan:
Complete heart block with bradycardia first troponin normal
Hypotension
Acute respiratory failure from above on ventilator-critical care consult
CT had a question ICH-Hygroma will discuss further with critical care
History of IDDM on SSI
History of Hypertension
SCDs
Please help me with ICD-10-CM codes in order.
Subjective:
Reason for admission hypotension complete heart block
Patient has a history of cancer of the breast. She developed severe headache and hence she called paramedics on the way the paramedics noted she was in complete heart block with a rate 30. In the ER she was intubated secondary to acute respiratory failure and hypotension. She is admitted to ICU. The CT scan of the head was suggestive of subdural fluid collection question CSF versus hygroma. Patient was given IV fluid challenge in ER and admitted to ICU for further care she has a significant comorbid condition of diabetes or hypertension. No fever or chills. Source of information ER records .
Assessment and Plan:
Complete heart block with bradycardia first troponin normal
Hypotension
Acute respiratory failure from above on ventilator-critical care consult
CT had a question ICH-Hygroma will discuss further with critical care
History of IDDM on SSI
History of Hypertension
SCDs
Please help me with ICD-10-CM codes in order.