CASE STUDIES Using the code book, code and answer questions about the following

Question

CASE STUDIES Using the code book, code and answer questions about the following case studies 9-1. CASE STUDY History and Physical CC: lleostomy reversal. HPI: Patient has finished treatment for her rectal cancer and wishes to have her ileostomy reversed. Preoperative workup is negative, and no contraindication to this procedure is present. The patient will also have her MediPort removed. Past medical history: Rectal cancer, hypertension, diabetes, and history of renal calculi. Social history: No tobacco, alcohol, or illicits. Married. Allergies: NKDA. Medications: Lantus insulin and Norvasc 5mg. ROS: Constitutional: No change in weight; no fatigue or fevers. Neuro: No headache or dizziness. HEENT: No vision problems or lymphadenopathy. CV: No chest pain, palpitations, or PND. Respiratory: No cough, SOB, or hemoptysis. Gl: No abdominal pain, NN, diarrhea, or dysphagia. GU: No dysuria or frequency Skin: No rashes or myalgias. Psych: No mood changes. PHYSICAL EXAMINATION: Vitals: Stable. General: No acute distress; normal affect. HEENT: PERRLA, EOMI, oropharynx clear, no nystagmus; neck has no masses; trachea is midline. Chest: CTA Breasts: Normal breast examination with no masses. Heart: RRR, no /R/G Abd: Soft, obese; ileostomy present. Joints: No acute changes. Skin: No rashes. Neuro: Alert, oriented, and answers questions appropriately. CN II through XlI intact. A/P: Rectal cancer, status post neoadjuvant therapy and a coloanal anastomosis to have a takedown of her stoma.

Explanation / Answer

9-1a- Ileostomy Reversal, Diabetes T-1

9-1b- Ileostomy Takedown, Reanastomosis, Removal of Medi-port

9-1c- Diabetes, Rectal Cancer, HTN.

9-1d- Fever, Constipation, HTN,

9-1e- Open ileostomy reversal or takedown

9-1f- Removal Of Mediport.

9-1l- It use as stool softner or treat Constipation

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