UPX Material - University of Phoenix



University of Phoenix Material

Gastrointestinal System – Analyzing a Progress Note

Part 1

Using 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 stabbing pain and cramping in the lower abdomen. Patient complains of anorexia, 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 diverticulitis along with GERD.

Past Medical History: Diverticulitis, GERD, Cholecystitis in 2011.

Meds: Nexium 20mg every day

Allergies: Sulfa, PCN

Assessment: Vital Signs: T 101 degrees, P 110, R 18, B/P 144/92, occult blood test negative.

GEN: Appear to be in acute distress, dehydrated, bowel sounds hyperactive x4, tenderness to left and right lower quadrant with guarding.

Impression: Acute Diverticulitis of the colon, possible gastritis

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.

|Medical term |Definition |Sources |

|1. | | |

|2. | | |

|3. | | |

|4. | | |

|5. | | |

|6. | | |

|7. | | |

|8. | | |

|9. | | |

|10. | | |

Part 2

Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.

|Medical term |Medical code |

|Anorexia |Z72.4 Inappropriate diet and eating habits |

| | |

| |R63.0 Anorexia |

| | |

| |F44.9 Dissociative disorder or reaction, unspecified |

| | |

| |F50.00 Anorexia nervosa |

|Gastritis |K29.70 Unspecified gastritis without mention of bleeding |

| | |

| |K29.20 Alcoholic gastritis, without mention of bleeding |

| | |

| |K29.81 Gastritis unspecified with bleeding |

| | |

| |K29.40 Chronic atrophic gastritis, without mention of bleeding |

|Diverticulitis |K92.0 Hematemesis |

| | |

| |K57.10 Diverticulosis of small intestine without perforation or |

| |abscess without bleeding |

| | |

| |K57.32 Diverticulitis of large intestines without perforation or |

| |abscess without bleeding |

| | |

| |N32.3 Diverticulum of bladder |

References

Centers for Medicare & Medicaid Services (23 Oct. 2014). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.” Retrieved from



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