What 6 icd-10-cm codes should be assigned


Problem: What 6 ICD-10-CM codes should be assigned for this? CHIEF COMPLAINT: Abdominal pain, nausea, vomiting, diarrhea HPI: Patient is disoriented, and we are unable to obtain hx from him. His girlfriend drove him to the clinic today; she states that he was up all-night vomiting. She denies any drugs, EtOH, tob. VITAL SIGNS: Ht 6'2, Wt 184, Temp 100.5, BP 110/75, HR 112 BPM GENERAL: This 26-year-old male is disoriented. He is experiencing hallucinations (trying to pet the dogs; there are no dogs here). Exam options are limited as patient is somewhat uncooperative. He is sweating but is shivering and states that he feels cold. He is dry-heaving. GI: Bowel sounds are irregular. No masses detected. Tender in RLQ, LLQ. SKIN: Warm and lacks moisture. DIAGNOSTIC: CBC, OB, WBC, Tox DX: General abdominal pain, nausea with vomiting, diarrhea, disoriented, hallucinations, fever

 

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