Case 1 PATIENT: Tom Smith DATE OF SERVICE: 9/10/XX
BLOOD PRESSURE: 140/90 WEIGHT: 164 PULSE: Rapid TEMPERATURE: 100
Tom was seen today at the request of his wife for what she suspects is a recurrence of his cocaine dependence.
On physical examination, the following was noted:
EARS, EYES, NOSE, AND THROAT: Pupils are dilated.
HEART: Heart rate is increased; blood pressure is 140/90.
ABDOMEN: Soft, nontender, no abnormal masses
PSYCHIATRIC: Oriented to time and place. Patient is very talkative and admits to not eating for the last 36 hours with no sleep for the last 48 hours. The lack of sleep is cocaine induced. Patient admits to using cocaine over the last month and recent days.
Referral made for inpatient treatment.
ICD-10-CM Code Assignment: