What is principal diagnosis code-secondary diagnosis codes

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Reference no: EM133988667

Assignment:

A 59 y/o male with significant past medical history of Htn, DM, ESRD, and trach dependence presented to ABC Hospital after a nurse at his nursing home noticed that his urine had a lot of sediment and was very abnormal. About 1 and 1/2 months ago the patient began retaining urine at which time he was seen by urology and a foley catheter was placed. About 2 weeks ago the foley was removed and patient was having his bladder scanned. Patient went a couple of days without requiring catheterization. He then got straight cathed for a few days. Patient was seen by Dr. Solomon and started on Bactrim and continues to be on it. Patient also states that the urology changed his Flomax to another drug that he cannot recall the name of. Today was the first time the patient was able to urinate on his own.

He was found to have sepsis 2/2 complicated with frequent catherization. Patient was started on Cefepime initially for his complicated UTI. Urine culture resulted positive for Enterococcus + VRE and his antibiotic was switched to Unasyn, for which he completed the entire course of abx. He had indwelling foley catheter in place for his urinary retention, but his urologist advised that his foley can be discontinued once he is discharged from the hospital.

Patient also has ESRD on dialysis T/Th/Sat. Dr. Solomon (his nephrologist) was consulted for inpatient dialysis. Initially, Dr. Solomon was planning on starting the patient on renal replacement and discontinue his dialysis. Patient is still making urine 500-1000ml of urine per day which is baseline for him. However, his electrolytes were becoming abnormal because he was not on his routine HD schedule. Patient was then restarted on dialysis the day before discharge. Patient will continue his HD schedule outpatient as recommended by Dr. Solomon. Mr. Greenwood will be discharged to long term care facility. Discharge planning discussed with patient, who agreed with plan.

What is the principal diagnosis code, secondary diagnosi(es) codes, principal procedure code, other procedure codes, and the DRG for this case?

Reference no: EM133988667

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