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Cellulitis of abdominal wall 2. Cellulitis of right leg 3. Cellulitis of left leg 4. Anemia 5. Hypokalemia 6. Hypertension 7. Hypothyroidism 8. Gastro-esophageal reflux disease 9. Panniculus 10. Endometriosis 11. Personal history of Methicillin-resistant Staphylococcus aureus infection 12. Acquired absence of small intestine 13. Acquired absence of uterus HOSPITAL COURSE: The patient was admitted to the hospital with greatly inflamed lower abdominal panniculus. She has had multiple surgeries there. Her white count was 14,000, with fevers. She was placed on oral Septra, IV Roceplin and IV Levaquin, and she responded quite nicely. Over the next 2 days, her white count went from 14,000 to 6,000, the cellulitis, warmth, erythema and tenderness went down. There was still a little erythema. She was feeling much better and no longer having fevers or chills. The blood culture showed no growth. Hematocrit was 37 at admission and 33 at discharge, but this was due to dilution. Her potassium was 3.6 at discharge. The patient was stable and sent home on Levaquin and Ceftin. Follow up with me in two weeks. Review Case 5-4, continued FST_Review_Case_5-4-new.indd 2 06/12/2018 19:35 M05_LAME5172_02_SE_C05.indd 168 06/03/2019 10:07 CHAPTER 5 Intermediate Inpatient Hospital Coding 169 HISTORY & PHYSICAL HISTORY: The patient has a long complicated medical history with multiple abdominal surgeries and multiple episodes of cellulitis. She comes in because she was a little nauseated last night and most of the day, and at about 6 o’clock today it hit with chills, her belly started getting red, tender and warm and she stated, “I’ve got the cellulitis again.” The patient has not vomited. PAST HISTORY: MEDICAL/SURGICAL: Yearly episodes of cellulitis of the abdomen. Hypertension. Hypothyroidism. Chronic hypokalemia. Chronic anemia. Chronic acid reflux from the bowel and stomach. Right ear surgery with MRSA infection many years ago. Status post T&A. Cesarean section times 1. Endometriosis. Hysterectomy for endometriosis, leaving the ovaries in and doing a supracervical hysterectomy; during that surgery, they injured the bowel and the patient got a severe infection where she was opened up, had a portion of the bowel removed and left open for approximately 7 months for healing. She has had over seven surgeries for skin grafting of such, as well as a partial bowel resection. From this, the patient has had an abdominal wall with just skin and no muscle, and this causes the cellulitis problems. MEDICATIONS: Metformin 500 bid, for endometriosis; lisinopril; phentermine 37.5 one daily; Synthroid 0.112 two daily; daily; triamcinolone/hydrochlorothiazide 37.5/25 one daily; Prevacid 30 b.i.d.; acidophilus one daily; citalopram 20 one daily. ALLERGIES: REGLAN and DEMEROL. PHYSICAL EXAMINATION: GENERAL: Alert and oriented, but appears sick. VITAL SIGNS: Blood pressure 146/70, pulse 136, respirations 20, temperature 104. HEENT: Unremarkable. LUNGS: Clear. HEART: Regular rate and rhythm. ABDOMEN: Large, with a scar forming a large diamond in the middle without any muscle tissue, you can feel the bowel right underneath. Across the panniculus and onto the legs there is a warm erythematous rash. ASSESSMENT: 1) Recurrent cellulitis of the legs and abdomen. 2) Anemia. 3) Hypokalemia. PLAN: Admit. Start on Levaquin 750 mg twice daily. Place her on Rocephin 2 grams now IV, then 1 gram IV q.24h. Septra DS, two pills now then one b.i.d. Will get blood cultures, CBC, comprehensive chemistry panel, C-reactive protein, and sedimentation rate. I will treat the anemia and hypokalemia and other problems as they occur.
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