Physician Office—Family Practice Patient: Jake Atkins Chief Complaint: “My stomach hurts, and I feel full of gas.” Expan

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Physician Office—Family Practice
Patient: Jake Atkins
Chief Complaint: “My stomach hurts, and I feel full of gas.”
Expanded Problem Focused History: This 37-year-old established
male patient presents with epigastric pain in the mid-abdominal
region associated with constant nausea and vomiting. He is unable
to keep down food or liquids. Pain is “severe and constant.” The
patient has had an estimated 18-pound weight loss over the past
month. He reports eating 12 pieces of bacon at a holiday breakfast
last week, which is when his symptoms started.
Expanded Problem Focused Examination: Vital signs reveal 99.8°F
temperature, otherwise normal. Abdomen is distended and tender
across upper abdomen. Guarding is present. Bowel sounds are
diminished in all four quadrants.
Assessment: Epigastric abdominal tenderness. Dehydration.
Suspected acute pancreatitis. (Medical decision making of moderate
complexity.)
Plan: Inpatient hospitalization. Orders documented and sent to
hospitalist. Patient’s spouse was notified of plan, and she will
transport to hospital by private vehicle now.
Instructions: Assign ICD-10-CM and CPT
code(s) for this case
ICD-10-CM: _______ , _______
CPT: _______