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**Consultation Report**

- **Date of Consultation:** 04/01/20XX
- **Referring Physician:** X, MD
- **Type of Consultation:** Nephrology
- **Reason for Consultation:** Abnormal renal function

**History of Present Illness:**
The patient is a 67-year-old lady referred by Dr. M due to abnormal renal function. She has a history of hypertension and thyroid cancer, recently treated with chemotherapy. Admitted five days ago with vomiting and dehydration, labs on admission revealed a BUN of 31 and creatinine of 2.0, which increased to a BUN of 65 and creatinine of 3.9. The patient has experienced hypotensive episodes. This consultation was requested to evaluate her renal condition.

**Allergies:**
The patient is allergic to ACE inhibitors, penicillin, and sulfa drugs.

**Past Medical History:**
1. Hypertension
2. Atherosclerotic heart disease (not coded due to lack of documentation as a current condition)
3. Hypothyroidism (not coded due to lack of documentation as a current condition)
4. Thyroid cancer

**Social History:**
The patient denies smoking, alcohol use, and drug use.

**Family History:**
The family history is noncontributory.

**Physical Examination:**
- **Vital Signs:** BP: 109/50, Pulse: 78 per minute, Respirations: 18 per minute, Temperature: 96.8
- **General:** The patient is awake, alert, and oriented times three, not in distress
- **HEENT:** Negative
- **Neck:** Supple with a positive mass in the anterior area
- **Lungs:** Clear to auscultation
- **Heart:** Normal S1 and S2
- **Abdomen:** Soft, non-tender, with normal bowel sounds
- **Extremities:** No pitting edema
- **Neurological:** Normal

**Laboratory Data:**
- Chemistry: Sodium 131, Potassium 3.9, Chloride 92, CO2 23, Glucose 84, Calcium 7.9, BUN 65, Creatinine 3.8
- CBC: White blood cell count 6.4, Hemoglobin 10.3, Hematocrit 30.8, Platelet count 122,000

**Impression:**
1. Chronic kidney disease, stage 3, with superimposed acute renal failure, likely secondary to over-diuresis and acute tubular necrosis due to hypotensive episodes
2. Thyroid carcinoma; a mass is present on the anterior neck; discussion about thyroid and mass removal needed
3. Hypertension (presumed relationship with CKD; report with a combination code)

**Recommendations:**
1. Strict intake and output
2. Urinalysis with microscopy
3. Intravenous fluids at 60 mL per hour
4. Discontinue diuretics
5. Renal ultrasound
6. Hold antihypertensive medication if blood pressure is equal to or less than 140/70
7. Continue current medication

I will follow up with the patient along with you. Thank you very much for allowing me to participate in the management of this patient.

**Signed by:** X, MD

**Question:** What are the diagnosis codes? Enter an ICD-10-CM code for each space provided.

Answer :

Final Answer:

1. N18.3 - Chronic kidney disease, stage 3

2. C73.9 - Thyroid carcinoma, unspecified

3. I10 - Essential (primary) hypertension

Explanation:

The patient's primary diagnosis is chronic kidney disease (CKD) stage 3 (ICD-10 code N18.3), with superimposed acute renal failure likely due to over-diuresis and acute tubular necrosis from hypotensive episodes. The secondary diagnosis is thyroid carcinoma (ICD-10 code C73.9), supported by the presence of a mass in the anterior neck. Additionally, the patient has a history of hypertension, and the presumed relationship between hypertension and CKD is coded using I10 for essential (primary) hypertension.

The CKD diagnosis is based on the elevated BUN and creatinine levels, indicating impaired renal function. The presence of a mass in the anterior neck supports the diagnosis of thyroid carcinoma. The hypertension diagnosis is justified by the patient's history of hypertension and its presumed relationship with CKD.

In summary, the final ICD-10-CM codes for this consultation report are N18.3 for CKD stage 3, C73.9 for thyroid carcinoma, and I10 for essential hypertension. These codes accurately capture the patient's current conditions and provide valuable information for billing, tracking, and analyzing healthcare data.

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Rewritten by : Barada

Final Answer:

1. N18.3 - Chronic kidney disease, stage 3

2. E07.9 - Thyroid carcinoma, unspecified

3. I10 - Essential (primary) hypertension

Explanation:

The patient's primary reason for consultation is chronic kidney disease (CKD) stage 3, denoted by the ICD-10-CM code N18.3. Additionally, the presence of thyroid carcinoma is indicated with the code E07.9, specifying an unspecified type of thyroid carcinoma. The third diagnosis involves hypertension, represented by the code I10.

In the medical report, the patient is diagnosed with CKD stage 3 with superimposed acute renal failure likely due to over-diuresis and acute tubular necrosis from hypotensive episodes. Furthermore, the report mentions the existence of a thyroid mass, indicating thyroid carcinoma, and recommends the removal of the thyroid and mass.

These ICD-10-CM codes provide a standardized way of representing the patient's diagnoses, facilitating communication among healthcare professionals and enabling accurate billing for medical services. Proper coding ensures a clear understanding of the patient's conditions and supports effective healthcare management.