what type of service is this case study and also the codes for the…
what type of service is this case study and also the codes for the… what type of service is this case study and also the codes for the procedure and the codes for the Lab. Also the Diagnosis coeds. Patient: Jeanne Raymond Chief Complaint: Nausea, vomiting, and abdominal pain. History of Present Illness: This new patient has had three episodes of midepigastric colicky pain, nausea, and vomiting during the past two weeks. There has been some diarrhea with these episodes. Stool is normal color; patient denies clay-colored stools. Past Medical History: The patient states she always has some degree of anorexia. No fatty food intolerance. No medications. Physical Examination: Vital signs are normal. Skin: No jaundice. Mucous membranes are moist.Eyes: Clear without icterus.Lungs: ClearHeart: Normal rate and rhythm.Abdomen: Soft with upper right quadrant tenderness to deep palpations, no guarding. Laboratory Data: White count was 14,300. Normal electrolytes. Amylase and lipase are within normal limits. Ultrasound of the gallbladder demonstrated a 1-cm stone in the gallbladder and no wall thickening. Ducts were not dilated. Diagnosis: Cholelithiasis. Plan: The case was discussed with the surgeon, who will see her for possible cholecystectomy in the near future. 6/20/20xx Health Science Science Nursing HITM 2224 Share EmailCopy link Comments (0)
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