Question Code in proper sequence! The following documentation is from the… Code

Question Code in proper sequence! The following documentation is from the… Code in proper sequence!The following documentation is from the health record of a 57-year-old male patient.Discharge Diagnoses:Lung cancer currently undergoing chemotherapy with Taxol and carboplatin with dexamethasoneType 2 diabetes, with neuropathy and nephropathy, poorly controlledHyperlipidemiaHepatomegalyHistory: This patient is a 57-year-old man who presented for outpatient chemotherapy. He had surgery for lung cancer in September and is now undergoing chemotherapy with Taxol and carboplatin, including dexamethasone as part of his chemo and prophylaxis for nausea. He has done very well with the chemotherapy. When he presented for outpatient treatment on the day of admission, he was found to be hyperglycemia. He is a known Type 2 diabetic. His diabetes is complicated by neuropathy and nephropathy. Due to his blood glucose levels, it was decided to postpone this chemotherapy session, and he was admitted for control of his diabetes.Dr. Johnson consulted with the patient to manage his diabetes regimen. He has been on 70/30 insulin, 25 units in the morning and 15 units in the evening. He had problems in the hospital with poorly controlled diabetes mellitus several times the first day, with blood sugar levels ranging from 30 to greater than 450. An IV insulin drip was started, and he also had q. 1 hour Accu-Checks. His hepatomegaly has enlarged from the last time that I saw him. Question whether this is fatty infiltration due to poor diabetes control, or whether there is now some involvement with metastatic carcinoma. The patient also continued his oral medications for hyperlipidemia during the hospital stay.Laboratory Data: Sodium 128, potassium 5.5, chloride 89, CO2 34, BUN 13, creatinine 0.8, glucose range 30-460, with final glucose of 210. Calcium 9.4, WBC 9.8, hemoglobin 11.6, hematocrit 34.3, platelets 277,000Plan: One difficulty here is the cyclic nature of his chemotherapy treatment regimen, likely to produce major shifts in his glucose, which is already difficult to control. The patient will need to monitor his glucose levels closely. He is discharged on 70/30 insulin, 35 units in the morning and 20 units in the evening. Dr. Johnson will be managing his diabetes, and the patient has instructions to call his nurse on a daily basis for the next week. He is to follow up with me for further chemotherapy in the oncology clinic next week. Flag question: Question 8Question 81 ptsCode Assignment Including POA IndicatorICD-10-CM Principal Diagnosis: Flag question: Question 9Question 90.5 ptsICD-10-CM Additional Diagnoses: Flag question: Question 10Question 100.5 ptsICD-10-CM Additional Diagnoses: Flag question: Question 11Question 110.5 ptsICD-10-CM Additional Diagnoses: Flag question: Question 12Question 120.5 ptsICD-10-CM Additional Diagnoses: Flag question: Question 13Question 130.5 ptsICD-10-CM Additional Diagnoses: Flag question: Question 14Question 140.5 ptsICD-10-CM Additional Diagnoses:  Health Science Science Nursing HIM MISC Share QuestionEmailCopy link Comments (0)

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