HISTORY AND PHYSICAL EXAM
39-year-old with RUQ pain for several months. She is gravida 0, para 0. She described the pain as sharp, severe. Her pain reoccurred several times, so she visited her PCP. An ultrasound was performed and gallstones were diagnosed.
Exam reveals slightly overweight female in no acute distress. Head, eyes, ears, nose, and throat are normocephalic and atraumatic. Lungs clear to auscultation. Breasts without masses. Abdomen soft and tender to palpation in the right upper quadrant.
Patient admitted for further evaluation and possible cholecystectomy.
DISCHARGE SUMMARY:
Patient was admitted and open cholecystectomy performed on day 2 for cholecystitis. Recovered satisfactorily without any complications and discharged on day 3.
Question
Assign the principal diagnosis, additional diagnosis(es), and inpatient procedure(s) as appropriate.
Principal ICD-10-CM code:
Additional ICD-10-CM code(s):
ICD-10-PCS Procedure: