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------------------------------------------------ Case Summary:

A 39-year-old woman presents with right upper quadrant (RUQ) pain for several months. She is gravida 0, para 0. She described the pain as sharp and severe. The pain reoccurred several times, prompting her to visit her primary care physician (PCP). An ultrasound was performed, and gallstones were diagnosed.

Physical Examination:

- Slightly overweight female in no acute distress.
- Head, eyes, ears, nose, and throat: Normocephalic and atraumatic.
- Lungs: Clear to auscultation.
- Breasts: Without masses.
- Abdomen: Soft and tender to palpation in the right upper quadrant.

Hospital Course:

- Patient admitted for further evaluation and possible cholecystectomy.
- Discharge Summary: Patient was admitted, and an open cholecystectomy was performed on day 2 for cholecystitis. The patient recovered satisfactorily without any complications and was discharged on day 3.

Coding:

- ICD-10 Code: [Insert appropriate ICD-10 code for cholecystitis and gallstones]
- CPT Code: [Insert appropriate CPT code for open cholecystectomy]

The patient's postoperative symptoms could suggest a possible infection. Gallstones cause pain when blocking ducts, necessitating surgical intervention. Relevant medical codes for cholecystitis and cholecystectomy are in the ICD-10 and CPT coding systems, respectively.

The patient's symptoms, including abdominal pain and fever following a cholecystectomy, may indicate a postoperative complication such as infection. Potential causes can include a urinary tract infection (symptoms of burning during urination and blood in the urine) or an infection in the abdominal cavity. Gallstones can cause issues including upper abdominal pain when they block ducts, possibly leading to the need for surgery. Risk factors for gallstones include obesity and diets high in calories and refined carbohydrates. The ICD-10 code for cholecystitis is K81 and the CPT code for cholecystectomy may vary but might include 47600 for an open procedure without exploration of the bile ducts.