SOLVED2826

Patient presents with flu-like symptoms present over the past several days. Some fever, chills, and sweats. Approximately a month ago had cough and cold symptoms and those seemed to have improved over the past week or so. No urinary symptoms, no changes in bowels. Also mentions some back pain. Does not appear short of breath. CBC showed normal white count. Liver panel are significantly elevated. Chest x-ray normal. VS are normal. HEENT, lungs and cardiac evaluation are normal. He has no tenderness or rebound in his abdomen. ASSESSMENT: Elevated liver enzymes with upper abdomen pain, probably cholelithiasis.Will admit and get an ultrasound in the morning Assign code(s) for facility services. Assign code(s) for facility services. ICD-10-CM: , CPT:
SCIENCE
HEALTH SCIENCE
NURSING

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