College

**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 through the courtesy of Dr. M because of abnormal renal function. The patient has a history of hypertension, thyroid cancer, and recent status post-chemotherapy. She was admitted five days ago with vomiting and dehydration. The labs on admission revealed a BUN of 31 with a creatinine of 2.0, which has increased up to a BUN of 65 and a creatinine of 3.9. The patient has also had hypotensive episodes. This consultation was requested for the evaluation of her renal condition.

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

**Past Medical History:**
1. Hypertension
2. Atherosclerotic heart disease
*(Do not code atherosclerotic heart disease; there is no documented support as a current condition.)*
3. Hypothyroidism
*(Do not code hypothyroidism; there is no documented support 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 any distress.

- **HEENT:**
Negative

- **Neck:**
The neck is supple. There is a positive mass in the anterior area of the neck.

- **Lungs:**
The lungs are clear to auscultation.

- **Heart:**
Normal S1 and S2

- **Abdomen:**
The abdomen is soft and non-tender. Bowel sounds are present and normal.

- **Extremities:**
There is no pitting edema.

- **Neurological:**
Normal

**Laboratory Data:**
The chemistry shows a sodium of 131, potassium of 3.9, chloride of 92, CO2 of 23, glucose of 84, calcium of 7.9, BUN of 65, and creatinine of 3.8. The CBC has a white blood cell count of 6.4, hemoglobin of 10.3, hematocrit of 30.8, and platelet count of 122,000.

**Impression:**
1. Chronic kidney disease, stage 3 (Primary reason for visit is chronic kidney disease stage 3) with superimposed acute renal failure, likely secondary to over-diuresis as well as acute tubular necrosis due to hypotensive episodes.
2. Thyroid carcinoma. The patient still has a mass on the anterior neck. Will discuss having the thyroid and mass removed.
3. Hypertension (Hypertension and CKD have a presumed relationship. Report with a combination code.)

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

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

**Signed by:** X, MD

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

Answer :

Final answer:

The patient's medical issues are codified as N18.3 for Chronic Kidney Disease, Stage 3, C73 for Thyroid carcinoma, and I12.9 for Hypertensive Chronic Kidney Disease, using the ICD-10-CM system.

Explanation:

The consultation report describes a 67-year-old patient with a complex medical history including hypertension, thyroid cancer, and abnormal renal function presenting with chronic kidney disease (CKD) stage 3, with an overlaid acute renal failure likely due to over-diuresis and acute tubular necrosis from hypotensive episodes.

Diagnosis codes that would appropriately represent this case include N18.3 for Chronic Kidney Disease, Stage 3, C73 for Thyroid carcinoma, and I12.9 for Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease, given the presumed relationship between hypertension and CKD necessitating a combination code. These codes are derived based on the ICD-10-CM classification system used for coding various medical diagnoses.