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Gastrointestinal System – Analyzing a Progress NotePart 1Using the following progress note, define the highlighted terms within the chart provided. This patient was assessed by an urgent care physician.Progress Note:40 y.o. female presents with a 3-day history of pain when swallowing and nausea. The patient complains of acid reflux, vomiting, and diarrhea with fever. She feels week and dehydrated. Patient notes having this before one year prior. She had a colonoscopy and endoscopy at the time and was diagnosed with esophagitis along with GERD. She denies pain in the abdomen.Past medical history: Diverticulosis, GERD, Cholecystitis in 2011.Meds: Nexium 20mg every dayAllergies: Sulfa, PCNAssessment: Vital Signs: T 101 degrees, P 110, R 18, B/P 144/92, occult blood test negative.GEN: Appear to be in acute distress, acute anemia secondary to upper GI bleeding with Melena with dropping hemoglobin from 11 to 8.Impression: Melena secondary to ulcerative esophagitis. Diverticulosis with bleed.Discussed with patient and planning transfer to University Hospital for direct admission. C. Bolling, CNP*Do not forget to include the sources for your definitions.40 Points: 1 point for Medical term, 2 points for Definition, and 1 point for SourcesMedical termDefinitionSources1.2. 3. 4. 5. 6. 7.8.9.10.Part 2Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.30 points: 10 for each correct answer. Medical termMedical codeMelenaK31.0 Acute dilation of stomachK92.8 Other specified diseases of the digestive systemK92.1 Melena K92.81 Gastrointestinal mucositis (ulcerative) Ulcerative esophagitisI85.00 Esophageal varices without bleeding. K22.11 Ulcer of esophagus with bleedingK29.81 Gastritis unspecified with bleedingK22.10 Ulcer of esophagus without bleedingDiverticulosisK92.0 HematemesisK57.32 Diverticulitis of large intestines without perforation or abscess without bleedingK57.91 Diverticulosis of intestine, part unspecified, without perforation or abscess with bleedingN32.3 Diverticulum of bladderReferencesCenters for Medicare & Medicaid Services (23 Oct. 2015). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.” ................
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