I need CPT Codes and ICD codes for the following case:

CASE 1-4 Initial Hospital Care

The patient in Case 1-4 is a 32-year-old male who was seen by his physician, Dr. Green, at the outpatient clinic. Dr. Green immediately admitted the patient to the hospital. Report Dr. Green's service.

LOCATION: Inpatient, Hospital

PATIENT: Jonathan Harley

ATTENDING PHYSICIAN: Ronald Green, MD

The patient, along with his wife, comes in today as he relates issues with worsening of his dyspepsia/GERD (gastroesophageal reflux disease). He relates that his medications are not working as previously noted since he has been removed from a proton pump inhibitor, Prevacid, to the Protonix secondary to insurance issues. He also relates to me issues of his worsening shortness of breath beyond his chronic status. This is more predominant with exertion. He has had worsening of daytime somnolence and sleep issues. He has had persisting fatigue over the course of the past 2 months as well as mild fluid gain.

SURGICAL HISTORY: The patient's past surgical history is positive for an appendectomy as a youth.

MEDICAL HISTORY:

1. Hypertension that has been under good control currently. 2. Asthma that is under fair control; the asthma is of chronic obstructive nature. 3. Chronic back pain, treated with a TENS (transcutaneous electrical nerve stimulator) unit. 4. Diverticulosis. 5. Dysphagia. CURRENT MEDICATIONS:

1. Albuterol inhaler 4 puffs q.i.d. (four times a day). 2. Allegra 180 mg (milligram) q.d. (every day). 3. Aspirin 325 mg, 6 tablets q.d. on a p.r.n. (as needed) basis. 4. Flovent inhaler 4 puffs b.i.d. (twice a day). 5. Labetalol 300 mg b.i.d. 6. Nasacort AQ 2 sprays b.i.d. 7. Norvasc 5 mg q.d. 8. Protonix 40 mg 1 tablet per day. He has been using 2 recently. 9. Serevent inhaler 2 puffs q.i.d. ALLERGIES: Ultram.

FAMILY HISTORY: Positive for emphysema in his father, who died at a young age from an accident. Mother is age 67, has had abdominal issues and surgery from noncarcinoma issues, about which he is nonspecific. The patient is the second of five children, having three brothers and one sister, all of whom are in good health.

SOCIAL HISTORY: The patient is disabled secondary to his chronic back pain. He is married. He relates eating a non-heart-healthy diet, high in fatty products. He is a nonsmoker. He averages 4 to 5 glasses of wine and 10 to 12 beers a week in alcohol intake. He has very limited exercise, including any active walking, secondary to his chronic back pain.

REVIEW OF SYSTEMS: No worsening of his headache issues. No change in mentation (activity of the mind). Hearing is gone in the right ear and diminished some in the left. His vision has been intact. Appetite has been good. He shows positive weight gain. He has no difficulty swallowing. He relates his dyspepsia/GERD has been worsening with some abdominal discomfort, postprandial specifically. He has had a nontender lower abdomen, predominantly the upper bothering him more. This radiates upward somewhat, specifically in his sleep. His sleep pattern has been disturbed. He relates chronic fatigue issues in the past month and has had worsening of the dyspepsia and GERD despite the use of proton pump inhibitor. No constipation; regular bowel movements. No dysuria or polyuria. Occasional nocturia. No aches or pains in the extremities but notes slight swelling of his legs. He has had some shortness of breath on exertion, specifically on stairways, but denies any type of chest pain of a cardiac nature. He relates immobility issues secondary to chronic pain as well as worsening shortness of breath.

PHYSICAL EXAMINATION: His examination today shows he is age 32 and is in no apparent distress. Slightly pale in color. Weight is 202 pounds. Height is 5 feet 5 inches. Blood pressure is 118/78. Pulse is 80 and regular. Respiratory rate is 20. He is afebrile at 96.4 F. HEENT (head, ears, eyes, nose, throat): Negative for discharge or deformity. The right tympanic membrane is severely scarred. The left shows a bolus-type effusion. No tenderness to the tragus, auricle, or mastoid process. Pupils are equal, round, and light accommodating. Nondilated funduscopy reveals no nicking or scarring. No tenderness of sinuses. Nasal and oral mucosa is pink and moist. There is extreme gag reflex elicited on attempt to view the posterior oropharynx. Neck is soft and supple. No lymphadenopathy. No supraclavicular nodes are noted. There are no carotid bruits. Cranial nerves II-XII are grossly intact. Lateralization Weber to the left as well as air-to-bone conduction being normal on the left and extremely reduced hearing on the right. Thorax: Scattered wheezes throughout; no crackles are noted. Cardiac: S1 (first heart sound) and S2 (second heart sound) with a 1/6 systolic murmur, best heard at the base on the right side of the sternum at the second and third intercostal space. This does not seem to change during inhalation, exhalation, or positioning. Abdomen is round, obese, with tenderness of the upper right quadrant with palpation as well as the epigastric region, which promotes some issue of reflux to the esophagus on deep palpation. The lower part of the abdomen is nontender. No rebound tenderness. Bowel sounds are present throughout. Normal-appearing male genitalia. Negative for inguinal hernia. Rectal exam reveals sphincter tone intact. Prostate is firm, mildly tender but more of a pressure sensation. Stool is guaiac negative for occult blood. There is 2 edema of the lower extremities. Skin is warm and dry. Sensation is intact.

LABORATORY DATA: Laboratory analysis conducted at this time for an amylase, lipase, comprehensive metabolic panel, CBC (complete blood count), TSH (thyroid stimulating hormone), T4 (thyroxine), lipid panel, PSA (prostate specific antigen) for screening, and H. pylori. Results at this time show his triglycerides to be 1410, total cholesterol 266. His hepatic panel shows his bilirubin total at 0.4. His AST (aspartate aminotransferase [formerly SGOT]) is 69 with ALT (alanine transaminase [formerly SGPT]) of 75. Total protein is 7.4. BUN (blood urea nitrogen) is 18, sodium 137, chloride 102, creatinine 0.8, glucose mildly elevated at 117. His albumin is 3.7, alkaline phosphatase 79. Amylase is 40. WBC (white blood count) 4.67, hemoglobin 14.6, hematocrit 42.2; monocytes elevated at 12.8. He is negative for H. pylori antibody.

PLAN: The patient will be admitted to general medical, with pancreatitis and shortness of breath with exertion. Vital signs will be q.4h. (every 4 hours) times three, then q. shift. He will have bathroom privileges. The patient will be n.p.o. (nothing by mouth). Will establish an IV (intravenous) of D5W (dextrose 5% water) half normal saline at 100 cc per hour. He will have sequentials on while in bed. I&Os (intake and output) will be done with daily weights on his chart. Will obtain an echocardiogram for Dr. Elhart to read and obtain a 1-day stress test if possible, and if the patient is in stable condition secondary to his shortness of breath on Monday or Tuesday at the time of his discharge. He will be on O2 (oxygen) on a p.r.n. basis per nasal cannula to keep saturations greater than 90%. He will receive albuterol nebs q.i.d. and p.r.n.; Flovent inhaler 4 puffs b.i.d. (twice a day); Serevent inhaler 2 puffs b.i.d. We will place him on Labetalol 20 mg IV b.i.d.; Nasacort AQ 2 sprays b.i.d.; and Protonix 40 mg IV q.d. Consideration for implementation of Tricor 160 mg as soon as the amylase and lipase are both showing negative.

Secondary to the patient's intense gag reflex, we will refrain from placing an NG (nasogastric) or Cor-Flo at this time and see whether adequate hydration and n.p.o. status will help resolve.

Chest x-ray was obtained via the dictation line, showing a stable appearance from the previous film, which had been done here in the clinic, free of any acute infiltrates.

His right upper quadrant underwent ultrasound, which was negative for cholelithiasis or cholecystitis, and the head of the pancreas appeared to be near normal from what was able to be visualized with the rest obscured secondary to bowel gas.

The patient will be admitted to the hospital. Discussion in the event of blood and blood products revealed that the patient has no religious beliefs contraindicating the aspect of the blood transfusion. The risks and benefits were explained, including transfusion reaction, hepatitis, HIV (human immunodeficiency virus), incompatibility, and other risks. The patient does agree to this, and I explained to him that unless it was an emergent situation, that discussion would be held again at the time if something did arise where he required blood, that there would be a further explanation discussing the risks and benefits of that being held. Both he and his wife agreed with this. He will be admitted at this time to the floor as a code level I.

CPT CODE(S): ______________________________________

ICD-10-CM DX CODE(S): __________________________________

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