What are the other diagnoses codes?! Patient DISCHARGE DIAGNOSIS: Fracture of neck of right femur ADMISSION HISTORY: The patient is an 88-year-old male who fell on the day of admission and s
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Patient DISCHARGE DIAGNOSIS: Fracture of neck of right femur
ADMISSION HISTORY: The patient is an 88-year-old male who fell on the day of admission and sustained a fracture of the neck of his right femur. The patient was admitted for a medical evaluation prior to surgical intervention.
COURSE IN HOSPITAL: Medical evaluation was obtained on admission. Patient was taken to the operating room, where an open reduction and internal fixation of the fracture of the right femur was performed. Postoperative course was complicated by urinary retention, which necessitated the placement of an indwelling Foley catheter. He was discharged with the catheter in place. The patient was ambulatory, nonweight bearing with a walker at the time of discharge.
INSTRUCTIONS ON DISCHARGE: The patient is instructed to follow up with my office in 3 days to remove staples and to begin outpatient physical therapy tomorrow. Home health services will follow this patient. Pain medications: Darvocet N 100, one tablet every 4 hours as needed for pain
Case two has one primary and 9 secondary diagnosis.
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