I need help with sequencing order for pts. dx.
the pt. has a driveline infection positive for pseudomonas
I would like to code it 996.09,041.7, 425.4,414.01
does my sequencing order and dx codes look correct, appreciate help, thanks
1. Driveline infection with culture positive for Pseudomonas.
2. Advanced ischemic dilated cardiomyopathy with ejection fraction less
than 20%, status post HeartMate II left ventricular assist device
placed in November 2014.
3. New York Heart Association Class IIIB to IV heart failure symptoms,
now improved to class I heart failure symptoms.
4. Coronary artery disease, status post remote bypass grafting surgery.
5. Dyslipidemia.
6. Hypertension.
DISCHARGE MEDICATIONS: Include a course of cefepime for 2 weeks along with
his baseline medications which include aspirin, warfarin, trazodone,
Protonix, Norvasc, Norco.
HISTORY OF PRESENT ILLNESS: gentleman, presenting with a purulent discharge from his driveline.
HOSPITAL COURSE: Patient was found to have suspected driveline infection.
Cultures were obtained. Patient was put on empiric antibiotics and an
Infectious Disease consult with Dr. was obtained. Patient was afebrile
with no significant leukocytosis. He had some tenderness around his
driveline site. The Cardiothoracic Surgery Service was also consulted.
Patient had an ultrasound of the driveline region showed no evidence of
abscess. Patient responded well to antibiotic therapy with no fevers and
complete resolution of this tenderness at the time of discharge.
LABORATORY DATA: Patient had a white count of 5.9, hemoglobin 12.4,
platelets of 216. INR of 3.0, creatinine of 0.84.
PHYSICAL EXAMINATION:
VITAL SIGNS: Patient is afebrile. Temperature is 36.8, pulse is 79, mean
arterial pressure was 86, saturating 99% on room air.
GENERAL: He is a well-developed gentleman, in no acute distress.
NECK: Supple. JVP is about 7 cm.
LUNGS: Apparently clear to auscultation bilaterally with good air movement.
CARDIAC: Notable for the HeartMate II ventricular assist device.
ABDOMEN: Soft, nontender. He had no significant exudate or tenderness
around the driveline with very minimal surrounding erythema, significantly
improved from the time of admission.
DISPOSITION: Patient will follow up in the Advanced Heart Failure Clinic in
the next 1-2 weeks' time. He was given standard precautions about when to
return to the emergency room including recurrence of his purulent discharge.
He also has ventricular assist device coordinators numbers to contact
immediately with any other concerns.
the pt. has a driveline infection positive for pseudomonas
I would like to code it 996.09,041.7, 425.4,414.01
does my sequencing order and dx codes look correct, appreciate help, thanks
1. Driveline infection with culture positive for Pseudomonas.
2. Advanced ischemic dilated cardiomyopathy with ejection fraction less
than 20%, status post HeartMate II left ventricular assist device
placed in November 2014.
3. New York Heart Association Class IIIB to IV heart failure symptoms,
now improved to class I heart failure symptoms.
4. Coronary artery disease, status post remote bypass grafting surgery.
5. Dyslipidemia.
6. Hypertension.
DISCHARGE MEDICATIONS: Include a course of cefepime for 2 weeks along with
his baseline medications which include aspirin, warfarin, trazodone,
Protonix, Norvasc, Norco.
HISTORY OF PRESENT ILLNESS: gentleman, presenting with a purulent discharge from his driveline.
HOSPITAL COURSE: Patient was found to have suspected driveline infection.
Cultures were obtained. Patient was put on empiric antibiotics and an
Infectious Disease consult with Dr. was obtained. Patient was afebrile
with no significant leukocytosis. He had some tenderness around his
driveline site. The Cardiothoracic Surgery Service was also consulted.
Patient had an ultrasound of the driveline region showed no evidence of
abscess. Patient responded well to antibiotic therapy with no fevers and
complete resolution of this tenderness at the time of discharge.
LABORATORY DATA: Patient had a white count of 5.9, hemoglobin 12.4,
platelets of 216. INR of 3.0, creatinine of 0.84.
PHYSICAL EXAMINATION:
VITAL SIGNS: Patient is afebrile. Temperature is 36.8, pulse is 79, mean
arterial pressure was 86, saturating 99% on room air.
GENERAL: He is a well-developed gentleman, in no acute distress.
NECK: Supple. JVP is about 7 cm.
LUNGS: Apparently clear to auscultation bilaterally with good air movement.
CARDIAC: Notable for the HeartMate II ventricular assist device.
ABDOMEN: Soft, nontender. He had no significant exudate or tenderness
around the driveline with very minimal surrounding erythema, significantly
improved from the time of admission.
DISPOSITION: Patient will follow up in the Advanced Heart Failure Clinic in
the next 1-2 weeks' time. He was given standard precautions about when to
return to the emergency room including recurrence of his purulent discharge.
He also has ventricular assist device coordinators numbers to contact
immediately with any other concerns.