Hello-
Here is the note I am working on. Patient had surgery back on 9/9/13 and has been dealing with non healing issues since. What DX codes would you use? Any help would be greatly appreciated! Thank you!
HPI-
presents today complaining of yellow/green liquid now pouring out of her G-tube tract resection site and
increasing nausea and epigastric discomfort. She denies dysphagia although she does report a dry mouth and
admits to poor hydration over the past several days. She denies fever or chills.
Additional Plan Details:
Non healing G-tube tract resection site with recurrent G-cutaneous fistula formation. Concern for possible distal
billio-pancreatic obstruction causing increased back pressure and recurrence of G-cut fistula.
1. CT abdomen to evaluate for dilated BP limb or any suggestion of BP limb obstruction
2. Balloon endoscopy may be indicated to dilate the J-J anastomosis if this has strictured.
3. Infusion center for hydration with pre-renal BUN/Cr ratio indicating dehydration
4. Alb 3.6, increase hydration to at least 64 oz/d and protein to at least 60 g/d
5. Maintain vitamin compliance
6. After JJ is addressed will likely need lap exploration and stapled closure of gastrostomy with re-tract excession.
Here is the note I am working on. Patient had surgery back on 9/9/13 and has been dealing with non healing issues since. What DX codes would you use? Any help would be greatly appreciated! Thank you!
HPI-
presents today complaining of yellow/green liquid now pouring out of her G-tube tract resection site and
increasing nausea and epigastric discomfort. She denies dysphagia although she does report a dry mouth and
admits to poor hydration over the past several days. She denies fever or chills.
Additional Plan Details:
Non healing G-tube tract resection site with recurrent G-cutaneous fistula formation. Concern for possible distal
billio-pancreatic obstruction causing increased back pressure and recurrence of G-cut fistula.
1. CT abdomen to evaluate for dilated BP limb or any suggestion of BP limb obstruction
2. Balloon endoscopy may be indicated to dilate the J-J anastomosis if this has strictured.
3. Infusion center for hydration with pre-renal BUN/Cr ratio indicating dehydration
4. Alb 3.6, increase hydration to at least 64 oz/d and protein to at least 60 g/d
5. Maintain vitamin compliance
6. After JJ is addressed will likely need lap exploration and stapled closure of gastrostomy with re-tract excession.