Discharge Summary History: The patient is a 70-year-old white male…

Discharge Summary History: The patient is a 70-year-old white male… Discharge SummaryHistory: The patient is a 70-year-old white male with chronic renal failure due to unknown etiology. He has had a renal transplant since 1977.  He has had presumed chronic rejection, and he is admitted at this time for the placement of an AV fistula in anticipation of chronic dialysis therapy. Hospital course: His history and physical examination are recorded elsewhere.  He was admitted on March 5th, and right radiocephalic AV fistula was performed on March 6th.  The bruit was excellent at the end of the care, and he was discharged on March 8th. Laboratory test revealed a white count of 10.5, hematocrit 21.3, platelet count 506,000, albumin 4.1, creatinine 7.78, BUN 99, uric acid 6.1, phosphorus 4.9, calcium 8.9, sodium 141, potassium 5.8, chloride 111, CO2 18. A repeat potassium was 3.9 after treatment with Kayexalate.  A chest x-ray was normal. EKG was normal.  His blood pressure remained in the 130/80 to 140/90 range on the antihypertensives that will be listed below. Assessment: 1. Creation of an AV fistula. 2. End-stage renal disease. 3. Hypertension. 4. Status-post renal transplant with chronic rejection. Plan: He will be discharged on the following medications: Kayexalate 2 tablespoons 1 a.m.; Imuran 50 mg 2 daily; Tenormin 100 mg daily; Zantac 150 mg b.i.d.; Loniten 5 mg b.i.d.; Prednisone 10 mg daily; Tylenol PRN. He will also be on Titralac 1 t.i.d./ Stuartnatal 1 + 1 daily; and Bicitra 1 tablespoon t.i.d. He will be followed in the dialysis unit. Operative ReportDiagnosis: End-stage renal disease, status post-transplant with rejection, hypertensive renal disease. Preoperative note: This patient with end-stage renal disease, status postop living renal transplant, now with rejection.  He is anticipated to need hemodialysis.  He is taken to the operating room at this time for the creation of an AV fistula at the right radial artery. Description of procedure: The patient was taken to the operating room and, after satisfactory axillary block of the right upper extremity, the arm was prepped and draped in a sterile fashion.  Patient was noted to have satisfactory right cephalic vein, and it was elected to investigate the possibility of creating a right radiocephalic AV fistula to provide needed bypass for dialysis.  A vertical incision was then created over the radial aspect of the distal forearm.  Sharp dissection was utilized to isolate a 4-cm segment of the cephalic vein. Venous branches were divided between 5-0 sild sutures.  A similar length of radial artery was isolated with branches being divided between 5-0 silk sutures.  A longitudinal venotomy was then created for a distance of 1.3 cm. A #4 Fogarty irrigating catheter was then passed proximally up the extremity to the level of the axilla with no evidence of outflow obstruction. A dilute Heparin solution was then instilled in the vein as the catheter was withdrawn.  An arteriotomy of similar distance was then created, and a side-to-side anastomosis was constructed with a running 7-0 Prolene suture. Prior to completion of the anastomosis, the proximal and distal vessel loops on the radial artery were alternately released to permit retrograde flushing and antegrade flushing of the system. The anastomosis was then complete, and all vessel loops were removed, and a satisfactory thrill was appreciated over the anastomosis.  It was elected to place a 3-0 silk tie around the cephalic vein distal to the anastomosis to prevent venous hypertension of the hand.  The wound was irrigated with saline and dilute Neomycin solution. Satisfactory hemostasis was noted. Subcutaneous tissues were closed with interrupted 3-0 Dexon sutures, and the skin approximated with interrupted 4-0 Ethilon sutures placed in a vertical mattress fashion.  The wound was covered with day gauze and vertically oriented tape to secure it in place, and the patient transferred to the ward, having tolerated the procedure well. Codes assigned are: Principal diagnosis: N18.6Additional diagnoses: NoneProcedure codes assigned: 031B0ZZAre these the correct codes per the clinical documentation and ICD-10-CM/PCS coding guidelines?  Is N18.6 the correct principal diagnosis per the clinical documentation and UHDDS guidelines? Are there any missing ICD-10-CM codes?  Health Science Science Nursing HIT 205 Share QuestionEmailCopy link Comments (0)

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