Question Answered step-by-step USE THE 1997 DOCUMENTATION GUIDELINES GENITOURINARY EXAMINATION…. USE THE 1997 DOCUMENTATION GUIDELINES GENITOURINARY EXAMINATION. UROLOGY OFFICE CONSULTATION REPORT. REASON FOR REFERRAL: RIGHT FLANK MASS, HEMATURIA. HISTORY OF PRESENT ILLNESS: The patient noticed the onset of hematuria following a motorcycle accident 1 week prior to admission. The patient denies dysuria or abdominal pain or distension and did not seek medical care for his symptoms until today. Past History: Medications: None, Illnesses: None, Operations: Tonsillectomy and adenoidectomy at age 8 years. Allergies: Allergic to Iodine and Shellfish. Review of Systems: Noncontributory. Physical Examination: General: The patient is a well-developed 26-year old Caucasian male in no acute distress who is oriented and cooperative. Vital signs: Pulse : 80/min. Blood pressure: 116/82. Respiratory rate: 20/min. HEENT: PERRLA. EOMs intact. Funduscopic examination shows no capillary aneurysms, hemorrhages or exudates. NECK: Supple with adenopathy. CHEST: Lungs: Clear to auscultation and percussion. Heart: RRR S1 and S2 present. No murmurs, bruits or rubs. ABDOMEN: Very  tender right CVA. There is a 15 cm palpable mass in the right upper quadrant and periumbilical region. The mass is freely moveable. Bowel sounds are normal.  No evidence  of hernia. Liver and spleen normal. Rectal: Deferred. Extremities: Normal. No clubbing, cyanosis or edema. No ulcers or trophic changes. Neurologic: Deffered. Database: Abdominal sonography reveals 15 cm mass in midpole right kidney with irregular texture and contour. No discrete fluid collectiions areseen. An IVP was deferred in view of patient’s history of iodine allergy, BUN 15, creatine 23, Urinalysis shows microscopic hematuria, proteinuria and 10-15 WBC, Specific gravity 1.020. ASSESSMENT: Right nephroma. Rule out renal cell carcinoma, subcapsular or intrarenal hematoma, or focal xanthrogranultomatous pyelonephrotitis. RECOMMENDATIONS: The patient’s history of trauma is probably unrelated to the mass in the kidney, due to the minor amount of discomfort the patient experienced and the abnormal accompanying laboratory values. It is most likely that this an incidental finding and due to renal cell carcinoma or adenocarcinoma of the kidney. Renal biopsy is recommended.  Both an ICD-10-CM code is needed and a E/M code is needed for this question ICD-10-CM :____________ E/M: _______________ Health Science Science Nursing NUR 540 Share QuestionEmailCopy link Comments (0)