I have coded the consultation as 99255 and the Endometrial uterine carcinoma as N80.0. I am unsure if I should code the surgery hysterectomy or the removal of the gallbladder. Because that was done before the consultation. Should I code the possible tachycardia or depression? What other diagnosis or procedures should I code?
CASE 11-2D
Oncology Consultation
Dr. Green requests that Dr. White, the oncologist, provide his opinion about the patient’s uterine cancer.
LOCATION: Inpatient, Hospital
PATIENT: Gladys Hardy
ATTENDING PHYSICIAN: Ronald Green, MD
CONSULTANT: Raphael White, MD, Oncology
REASON FOR CONSULTATION: Endometrial uterine carcinoma
HISTORY OF PRESENT ILLNESS: The patient is a 62-year-old white woman who had been seen at the beginning of May by Dr. Martinez for vaginal bleeding. The evaluation included D&C (dilation and curettage). She has had perforation of the uterus. Surgery of total abdominal hysterectomy had been performed for a tumor of the uterus. A porcelain gallbladder had been found and this had been also removed. Postoperatively, she has recovered relatively promptly, started feeding, and has had bowel movements. She required fluid support and because of this she probably has developed tachycardia in the range of 175 with blood pressure dropped from 160 systolic to 120. She had been treated with digoxin and diltiazem and had been transferred to the surgical ICU (intensive care unit) and started on esmolol. Electrolytes also had been replaced. At this point, she gives no specific complaints. She feels somewhat depressed and scared by the whole situation.
PAST MEDICAL HISTORY: Past medical history has been insignificant. She has had no illnesses, injuries, or surgeries.
Her only medications have been multivitamins and calcium.
SOCIAL HISTORY: She is a retired bookkeeper. Lives together with her husband in Manytown. There is no history of tobacco abuse or alcohol abuse.
She has no known allergies.
FAMILY HISTORY: Notable above for colon cancer and breast cancer. There is also heart disease in the family. No significant history of dyslipidemia, diabetes, osteoporosis, or history of ovarian cancer.
REVIEW OF SYSTEMS: Except for the events in the hospital associated with tachyarrhythmia, she has had no chest pain, cough, shortness of breath, nausea, or vomiting. Constitutional: There is no history of any significant weight loss. My appetite has been good. There is no history of fevers. HEENT (head, ears, eyes, nose, throat): She uses glasses. No significant change in vision. No blurred or double vision. No change in hearing or swallowing problems. No new headaches. No new neck stiffness. She has arthritis in the left shoulder that has been present for a long time. Respiratory: She has had no history of exposure to tuberculosis. No pneumonia. No chronic history of any shortness of breath, cough, or expectoration. No hemoptysis. Cardiovascular: No significant prior history. No palpitations or chest pain. Gastrointestinal: No history of abdominal pain. No history of gastroesophageal reflux, regurgitation, peptic ulcer disease, or recent change significant of bowel habits. No melena or hematochezia. No mucus in the stool. Genitourinary: She has had complaints of stress urinary incontinence. Gynecologic: There is postmenopausal bleeding for which she had surgery. She is part (to bring forth) 2. She has had uncomplicated deliveries. She has a son and daughter who are living close by and are essentially healthy. She has not been on hormonal replacement treatment. Musculoskeletal: She has complaints consistent with osteoarthritis, pain mainly in the left shoulder that had been present for a long time. Neurologic: No history of stroke, seizures, loss of consciousness, paresis, tingling, or numbness. Hematologic: No history of easy bruising or bleeding prior to postmenopausal bleeding. No history of blood transfusions. Lymphatic: No history of lymph node enlargement. Endocrine: No history of polydipsia. No cold or heat intolerance. Immunologic: No history of hives or recurrent frequent infections. Psychiatric: No history of major depression or psychosis.
PHYSICAL EXAMINATION: She is alert and oriented times three; was in apparent distress while in the ICU. Blood pressure at present is in the range of 122-150/70-80. Pulse is in the range of 79; it reaches 120-130 at times. The respiratory rate is 16. She is afebrile. Normocephalic and atraumatic. Eyes: PERRLA (pupils equal, round, reactive to light and accommodation). No jaundice. No extraocular muscle movement. No sinus tenderness. Clear oral and nasal mucosa. Tongue and uvula midline. No pharyngeal exudates, erythema, or thrush. The ear canals are clear. The neck is supple. No JVD (jugular vein distention). Trachea midline. Nonpalpable thyroid. No palpable cervical, supraclavicular, axillary, or inguinal lymph nodes. Lungs are clear to auscultation and percussion bilaterally. Heart: S1 (first heart sound) and S2 (second heart sound). No gallop or rub. No significant murmur. Breast exam: No palpable mass or nipple discharge. The abdomen is soft and nondistended. Bowel sounds are present and hypoactive. Difficult to examine, she has had recent surgery but no palpable masses or organomegaly. Extremities: There is no cyanosis, clubbing, or edema. Pulses are present. Neurologic: There are no focal motor, sensory, or cranial nerves II-XII deficits. Muscle tone and reflexes are grossly within normal range. She shows appropriate insight and judgment. The mood is somewhat depressed. The effect is grossly normal.
Her ECG (electrocardiogram) and monitor slips have shown episodes of V-tach (ventricular tachycardia), episodes of atrial fibrillation, and some slowed PR (pulse rate) intervals. Dr. Martinez has considered WPW (Wolff-Parkinson-White syndrome).
LABORATORY DATA: White blood cell 15.27, hemoglobin 12.4, hematocrit 35.2, platelets 186, and normal red cell indices. Differential: Increased neutrophils 88.6%, decreased lymphocytes 5.7%, monocytes 5%, eosinophils 0.6, and basophils 0.1%. Basic metabolic panel: potassium 3.5, glucose 123, and calcium 7.4. The rest is within normal range. PT/INR (prothrombin time/International Normalized Ratio) today has been 13 and 1.2. Magnesium was normal at 1.7, and phosphorus decreased to 0.3. Urine culture has been done but is not available yet. LDH (lactate dehydrogenase) was 143. Troponin had been 0.08. The pathology results from the surgery have concluded with endocervical cuttings and benign endocervical mucosa; the uterus has shown endometrial adenocarcinoma endometrioid-type, predominantly grade 1 with focal areas of FIGO (International Federated Gynecological Oncology) grades 2 and 3 with focal invasion limited to the inner third of the myometrium. Left ovary, fallopian tube, no pathologic diagnosis. Multiple intramural and subserosal leiomyomata showing the myometrium, benign, right ovary, and fallopian tube portion of the benign ovary and fallopian tube. The gallbladder has shown extensive calcification.
ASSESSMENT: A 62-year-old patient has had recent surgery at this point and is in critical condition, namely because of cardiac arrhythmias probably related to fluid overload related also to medications. She has been started in the hospital on Peri-Colace, Zoloft, azithromycin, cefotaxime, and Zofran, and Tylenol has been given. In terms of uterine cancer, cancer seems to be early stage. As per the available data, the tumor is T1B, N0, M0, the stage is IB endometrioid carcinoma, low grade in most of the tumors. No evidence of any intravascular, or perineural spread. These are also associated, most likely, with stress leukocytosis as well as electrolyte abnormalities. The patient at this point is still in critical condition in terms of her cardiac function. She has been monitored. Anticoagulation has been planned considering a relatively prolonged hospital stay, and at this point, she is bedridden in the ICU. Dr. Green has started the replacement of electrolytes and anticoagulation. She has been kept n.p.o. (nothing by mouth) with consideration of possible ileus. Aside from this, her immediate problems, which will be managed by Dr. Green in terms of uterine cancer, the only disturbing factor is the fact that there was perforation of the uterus during D&C, which may have caused some spilling of tumor cells in the pelvic area. Still, this is not a justifiable consideration for any additional adjuvant treatment. The recommendation in her case would be after stabilization of her condition in several weeks to perform CT (computerized tomography) scans to evaluate for any pelvic, periaortic, possible adenopathy, which at her stage of cancer is not very likely. As there was tumor spilling, the risk for recurrence of such an early-stage uterine cancer is minimal, and studies would be indicated it is less than 10% over 5 years. Considering these facts, no additional treatment would be recommended; yet a cautious approach with obtaining imaging studies, a CT scan of the pelvis and abdomen could be considered once she is stable, and if those are negative, further follow-up could be done on a clinical basis. The patient herself is not willing to proceed with any aggressive treatment, which again in her case is not recommended and most likely will not be needed in the future either. She will need regular gynecological follow-ups as well as mammograms as per guidelines. I would be glad to follow up with her in 1 to 2 months when she would be able to have the CT scans done. I appreciate the opportunity to see this pleasant lady, who in terms of her uterine cancer would have a very likely good prognosis
