[Expert Solution]: LONG, BETHIPCase001Dr

LONG, BETHIPCase001Dr. BLACKAdmission: 04/26/YYYYDOB: 12/17/YYYYADMISSION DATE: 04/26/YYYYROOM: 369ADMISSION DIAGNOS IS: Fever of undetermined origin.DISCHARGE DIAGNOSIS : Acute pyelonephritis.DIsCHARGE SUMMARYDISCHARGE DATE: 04/30/YYYYDD: 04/30/YYYYSUMMARY : This 30 year old white female had high fever off and on forseveral days prior to admission without any localizing signs or symptoms.Preliminary studies done as an outpatient were unremarkable except toindicate an infection some place. She was ultimately seen in the office,temperature was 103 to 104. She was becoming dehydrated, washed out, weak,tired, and she was admitted for further workup and evaluation.DT: 05/01/YYYYWorkup included a chest x-ray, which was normal. Intravenous pyelogram wasalso normal . Blood culture report was normal. Urine culture grew outEscherichia coli qreater than 100, 000 colonies. Throat culture was normalOne blood culture did finally grow out an alpha strep viridans.I talked to Dr. Burke about this and we decided on the basis of herclinical condition and the fact that this did not grow on all bottles itwas more likely a contaminate. Urine showed a specific gravity of 1.010,albumin 1+, sugar and acetone were negative, white blood cells 6 to 8, andred blood cells 1 to 2. White count 13, 100, Hemoglobin 12, hematocrit 35.1,segmental cells 81, lymphocytes 11, monocytes 5, eosinophils 1, bands 2.Mononucleosis test was negative. Alkaline phosphatase 127, blood sugar 125,sodium 142, potassium 4.7, carbon dioxide 30, chloride 104, cholesterol119, Serum glutamic oxaloacet ic transaminase 41, lactate dehydrogenase 151,creatinine 0.9, calcium 9.8, phosphorus 3.3, bilirubin 0.6, total protein6.8, albumin 4.0, uric acid 6.5. Electrocardiogram was reported as normal,She was started on intravenous fluids, intravenous Keflex, her temperatureremained elevated for approximately 48 hours and now has been normal forthe last 48 to 72 hours. She feels better, hydrat ion is better, eatingbetter, no urinary symptoms. She’s being discharged at this time on Keflex500 four times per day, increased fluid intake. To be seen in follow up inthe office in 1 week.Reviewed and Approved: John Black MDATP-B-S: 02:1001261385: John Black MD(Signed: 5/1/YYYY 2:24:44 PM EST)Physician AuthenticationGLOBAL CARE MEDICAL CENTER 100 MAIN ST, ALFRED NY 14802 (607) 555-1234 assign icd 10 pcs code for the scenerio.