Natasha Abernathy is a 52-year old female who presents to the ED with left lower

Natasha Abernathy is a 52-year old female who presents to the ED with left lower quadrant cellulitis. The patient has an incision site that has opened up and started draining. Patient states she had a venous bypass graft done 9 days ago by Dr. Johnson. She states yesterday she was seen by the home health nurse who became concerned the area was becoming infected as it was necrotic appearing around the incision on the pannus with foul drainage. The patient states she is having diffuse pain all over the abdomen which she rates as a 9/10 and worse with palpation of the abdomen. She admits to fever and chills, nausea. Patient denies chest pain, SOB, vomiting, diarrhea. Review of Systems: As noted in the HPI. All other ROS are negative. Past Medical History: GERD, ESRD on HD (MWF), mixed hyperlipidemia, OSA, htn, asthma Past Surgical History: Appendectomy, cholecystectomy, TAH, AV shunt creation, EGD w/ endoscopic US Allergies: Aspirin, Cipro, Dilaudid, Flagyl Medications: Augmentin 500/125 mg, Oxycodone, Rantidine, Fluticasone, Albuterol, Lipitor, Losartan, Nifedipine, EPO ED Triage Vitals: BP: 120/56 Pulse: 88 BPM Resp.: 12 RPM Temp: 101°F SpO2: 95% Physical Exam: Constitutional: Appears comfortable and in no acute distress. Head and Face: Normocephalic atraumatic. Eyes: Normal sclera and conjunctiva. PERRL. Ears: External ears normal Oropharynx: MMM Cardiovascular System: Normal heart sounds, +S1/S2, RRR. Respiratory System: Normal effort. CTA bilaterally. No wheezing, rales or rhonchi Gastrointestinal: Diffuse tenderness to palpation, non-distended, normal bowel sounds Integumentary System: Incision site on left side of pannus small 1 cm opening with drainage, erythema, black dislocation around wound. Upper Extremities: L arm fistula Lower Extremities: Lower extremities are normal. Neurologic System: A&Ox3. Vascular: intact distal pulses of all extremities. The following differential diagnosis was considered but not limited to the following: necrotizing fasciitis, cellulitis, abscess formation. The following tests were performed and reviewed: Results for orders placed or performed during the hospital encounter of 06-19-XX Laboratory: CBC/DIFF WBC: 12.86 (H) (Ref Range 4.00 – 10.80 K/ul) RBC: 2.66 (L) (Ref Range 3.85 – 5.15 M/ul) HGB: 84 (L) (Ref Range 12.0 – 15.3 g/dl) HGT: 27.0 (L) (Ref Range 36.0 -45.2 %) MCV: 101.5(H) (Ref Range 81.5 -97.5 fl) MCH: 31.6 (Ref Range 27.0 – 34.0 pg) MCHC: 31.1 (L) (Ref Range 32.0 – 36.0 g/dl) RDW: 15.8 (H) (Ref Range 11.5 – 15.5 %) Platelet Count: 162 (Ref Range 140-400K/uL) MPV: 10.6 (Ref Range 6.6-11.1fL) NEUTS: 79.4 (H) (Ref Range 40- 75 %) LYMPHS: 7.0 (L) (Ref Range 18 -42 %) MONOS: 9.6 (Ref Range 1 – 11 %) EOS: 1.9 (Ref Range 0-6 %) BASOS: 0.3 (Ref Range 0-2 %) IMMATURE GRANULOCYTE: 1.8 (Ref Range 0-2 %) ABS. NEUTS: 10.20 (H) (Ref Range 1.8 – 7.7 K/ul) ABS. LYMPHS: 0.90 (L) (Ref Range 1.0 – 4.8 K/ul) ABS. MONOS: 1.24 (H) (Ref Range 0.0 – 1.1 K/ul) ABS. EDS: 0.25 (Ref Range 0.0 – 0.7 K/ul) ABS. BASOS: 0.04 (Ref Range 0.0 – 0.2 K/ul) ABSOLUTE IMMATURE: 0.23 (H) (Ref Range 0.0 – 0.2 K/ul) Basic Metab Panel BMP BUN: 20 (Ref Range 6 – 20 mg/dl) CREATININE: 4.1 (H) (Ref Range 0.5 – 1 .0 mg/dl) SODIUM: 135 (Ref Range 135 – 146 mmol/L) POTASSIUM: 3.5 (Ref Range 3.5 – 5.1 mmol/L) CHLORIDE: 92 (L) (Ref Range 98 – 107 mmol/L) CO2: 29 (Ref Range 22 – 32 mmol/L) ANION GAP: 14 (Ref Range 7 – 15 mmol/L) GLUCOSE: 123 (H) (Ref Range 70 – 120 mg/dl) CALCIUM: 8.3 (L) (Ref Range 8.4 – 10.2 mg/dl) E GLOM FILTRATE: 11.1 (L) (Ref Range >60) Hep Function Panel ALBUMIN: 3.2 (L) (Ref Range 3.8 – 5.0 g/dl) AST: 29 (Ref Range 10 – 35 U/L) ALKALINE PHOSPHATASE: 139 (Ref Range 0 – 153 U/L) ALT: 20 (Ref Range 10 – 35 U/L) BILIRUBIN, TOTAL: 0,3 (Ref Range 0- 1.2 mg/dl) BILIRUBlN, DIRECT: <0.2 (Ref Range 0 - 0.3 mg/dL) PROTEIN: 6.5 (Ref Range 6.0 - 8.3 g/dl) PT/INR PT/INR-PT: 69.6 (H) (Ref Range 11.5 - 14.6 seconds) PT/INR-INR: 9.16 (HH) (Ref Range 0.85-1.16) Lactate LACTIC ACID: 0.9 (Ref Range 0.4 - 2.5 mmol/L) Sedimentation Rate SEDIMENTATION RATE: 120 (H) (Ref Range 0 - 20 mm/hour) Renal function Panel ALBUMIN: 2.5 (L) (Ref Range 3.8-5.0 g/dL) CALCIUM: 7.5 (L) (Ref Range 8.4-10.2 mg/dL) CO2: 25 (Ref Range 22-32 mmol/L) CHLORIDE: 95 (L) (Ref Range 98-107 mmol/L) CREATININE: 4.4 (H) (Ref Range 0.5-1.0 mg/dL) GLUCOSE: 121 (H) (Ref Range 70-120 mg/dL) PHOSPHORUS: 4.1 (Ref Range 2.5-4.8 mg/dL) POTASSIUM: 3.5 (Ref Range 3.5-5.1 mmol/L) SODIUM: 136 (Ref Range 135-146 mmol/L) BUN: 22 (H) (Ref Range 6-20 mg/dL) ANION GAP: 16 (H) (Ref Range 7-15 mmol/L) E GLOM FILT RATE: 10.1 (L) (Ref Range >60) Lactate Whole Blood LACTIC ACID W BLOOD: 1.0 (Ref Range 0.4-2.5 mmol/L) Magnesium MAGNESIUM: 1.9 (Ref Range 1.5-2.6 mg/dL) Medical Decision Making History and physical were obtained. The patient’s constellation of clinical and laboratory findings is consistent with severe cellulitis. CT scan demonstrates subcutaneous air with no discrete abscess formation. Incision site appears clinically infected. Patient’s laboratory testing revealed elevated WBC and vascular surgery evaluated the patient who recommended admission. Based on the patients age, coexisting illnesses, labs, imaging, and exam findings the decision to treat as an inpatient was made. I discussed my findings with the patient and they understand and agree with the treatment plan. All questions answered. Final Diagnosis: Necrotizing fasciitis Secondary Diagnoses Managed in ER: Hypertensive CKD, stage 5. End Stage renal disease Renal dialysis status. Disposition: Admit to inpatient Electronically Signed By: Lisa Stokely, MD Imaging ReportDate of Service: 06-19-XX Exam: Ct Abdomen /Pelvis Without IV Contrast Without Oral Clinical History: Abdominal wound, pain, drainage, dialysis patient Technique: Upright PA and lateral views of the chest Findings Lines and Devices: Left-sided presumably subclavian to femoral artery stent graft, partially visualized. Liver: Unremarkable. Bile Ducts: Within normal limits post cholecystectomy. Gallbladder: Surgically absent. Pancreas: Unremarkable. Spleen: Splenomegaly is unchanged Adrenals: Unchanged in size and morphology. Kidneys/Ureters: The kidneys are atrophic. There is a stable exophytic lesion arising from the right kidney, likely a cyst. Bladder: Collapsed. Bowel: Diverticulosis of the colon without diverticulitis. Lymph Nodes: Unremarkable. Vessels: Atherosclerotic changes. Reproductive Organs: Status post hysterectomy. Peritoneum/Retroperitoneum: No free fluid or pneumoperitoneum. Abdominal Wall/Soft Tissues: There is diastases of the anterior abdominal wall with a fat containing ventral abdominal wall hernias. There is marked inflammatory stranding and subcutaneous air within the left lower quadrant abdominal wall which partially surrounds the distal aspect of the bypass graft. There is a small amount of non loculated fluid in the left lower quadrant. No discrete loculated collection identified. Bones: There are degenerative changes of the spine with prominent sclerosis of the endplates, as can be seen with hyperparathyroidism. Impression: Subcutaneous inflammatory stranding and fluid within the anterior left lower quadrant abdominal wall without a discrete collection. Findings most likely represent inflammatory phlegmon. Inflammatory changes partially surrounds the subclavian artery to left common femoral artery stent graft. Infection of the stent graft is not excluded. Chronic findings, as above. What are the 6 ICD-10 codes

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