Reference no: EM133746727

Question

HCC Codes for Chief Complaint: Pt coming from the Assisted Living facility with episodes of coffee ground emesis around 0500 and has had tarry black stools. History of Present Illness: Patient is a 75 year old female with history of chronic dementia currently living in a dementia care type facility noted to have tarry bowel movements and also coffee-ground emesis x2. Patient had a similar admission about 4 months ago. At that time she presented with the anemia and she was treated symptomatically with transfusion, however family did not want any invasive workup such as endoscopy or colonoscopy secondary to DNR and comfort measures only. Patient presents with similar presentation having multiple BMs with dark bowel movement and also coffee -ground emesis. She was found to have a hemoglobin of 3.9 she did receive blood transfusion and the emergency room physician requested the patient to be admitted to hospitalist service for further monitoring. Patient's blood pressure was low with fluids and it improved to 100/70. Patient's son is at the bedside and he confirms the patient is DNR and did not want aggressive measures such as endoscopies but agreeable for blood transfusions, IV fluids administration and hospital admission. Patient husband.