Four months ago, this 18-year-old female was hospitalized due to epigastric abdominal pain, lack of appetite and weight loss. She was diagnosed with Crohn’s disease. Hepatic biopsy, that was
PATIENT: ALBESSI, CARLINA
ACCOUNT/EHR #: A018-042365997
DATE: 04/18/18
Attending Physician: Harriet Sarreh, MD
Four months ago, this 18-year-old female was hospitalized due to epigastric abdominal pain, lack of appetite and weight loss. She was diagnosed with Crohn’s disease. Hepatic biopsy, that was performed during this hospitalization, showed evidence of an overlap syndrome (cholangitis/hepatitis). She was initially treated with Cortisone and Azathioprine.
During the last 4 months, the patient was hospitalized 7 times. She had recurrent attacks of infective cholangitis.
She was treated with antiobiotics and papillotomy through ERCP. Later on, laparoscopic cholecystectomy was carried out. During postsurgery, after a short period of wellness, the patient suffered from an abdominal pain. Reappearance interpreted, at the beginning, as a light pancreatitis (treated with antibiotic therapy). Subsequently, persisting painful crises were observed despite blood tests substantial stability.
Therefore, a MR cholangiography was carried out and revealed an appearance of intra- and extrahepatic bile duct dilatation, evident also at common bile duct level where the picture seems revealing a relevant stenosis. A biliary stent was placed during ERCP in order to guarantee bile ducts patency.
After the procedure, the patient was hospitalized twice due to ascending cholangitis. US showed an occlusion of the biliary stent with overlapped cholangitis. Following the US, an antibiotic therapy has been started with Meropenem, and an ERCP was carried out. ERCP didn’t show any materials obstructing the stent. Biliary washing was within normal limits.
Today’s admission is due to reappearance of epigastric pain in the attempt to interrupt the antibiotic therapy.
Personal History:
1 year old: Roseola.
4 years old: Salmonellosis.
6 years old: Varicella.
Clinical History:
Four months ago hospitalization following epigastric abdominal pain, at times postprandial, from 2 weeks linked to ingravescent lack of appetite and weight loss (3 kg in a month). During hospitalization the most significant medical tests carried out were
– Ultrasound scan and MR cholangiography with evidence of bile ducts dilatation.
– Endoscopy of the bowel with evidence of terminal ileitis and colitis with histologic diagnosis of Crohn’s disease.
– Hepatic biopsy with evidence of an overlap syndrome picture (cholangitis/hepatitis).
– Lab examinations with finding of elevated levels of IgG (2937) and positive results of C-ANCA antibodies.
During this hospitalization, bringing back the antibiotic therapy. Abdomen ultrasound scan with evidence of common bile duct dilatation. Therapy started with Cortisone 50 mg IM and Azathioprine 100 mg IV. Her condition progressively improved and allowed her discharge with the following therapy:
Augmentin (1 g × 3); Ciproxin (500 mg × 2); Folina 5 mg (1 tablet every other day); Deltacortene (15 mg daily); Azathioprine (100 mg daily); Lansoprazole (30 mg daily); Ursodesossicolic Acid (300 mg 4 times a day).
Differential Diagnosis: Primary Sclerosing Cholangitis (PSC) with either Crohn’s disease (CD) or more likely Ulcerative colitis (UC) pancolitis
I need help finding the codes
You’re looking for:
Three diagnosis codes
Connect wants K83.0 for the first code, but this is incomplete. It should be K83.01.
Connect considers the cholangitis to be a complication of the other two codes. I’m not convinced I would code it that way, though unless the physician specifically documented a relationship between those conditions.
There’s also an Excludes 1 note that says we can’t code two of those codes together. On the job, this would be a good case to query the physician for more information.
Three PCS procedure codes
None of them start with 0.
The patient has an extensive history documented. Be sure to read carefully to tell what was done on this admission vs. previous admissions.
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