Medical report of 50 year-old Iraqi male suffering from the effects of a gunshot wound to the stomach. Medical procedures included, resection of transverse colon; exploratory Laparotomy; colonoscopy; and endoscope of Small Intestine. Follow-up treatment is home care.
—1
US ARMYIIIM
3 .4
Gender : Male Age :50 Disposition : Home, Self Care (1) Disch Date : 05/07/2003
Medicare DRG
148 MAJOR SMALL AND LARGE BOWEL PROCEDURES with CC
CMS wt 3.4503 A/LOS 12.3 G/LOS 10.2
Principal Diagnosis *86352 TRANSVERSE COLON INJURY, WITH OPEN WOUND INTO CAVITY
Secondary Diagnoses *86330 SMALL INTESTINE, UNSPECIFIED SITE INJURY, WITH OPEN WOUND INTO CAVITY #9974 DIGESTIVE SYSTEM COMPLICATIONS, NOT ELSEWHERE CLASSIFIED #486 PNEUMONIA, ORGANISM UNSPECIFIED #5185 PULMONARY INSUFFICIENCY FOLLOWING TRAUMA AND SURGERY #496 CHRONIC AIRWAY OBSTRUCTION, NOT ELSEWHERE CLASSIFIED #2762 ACIDOSIS 5768 DISORDER OF BILIARY TRACT 3051 TOBACCO USE DISORDER E8784 RESTORATIVE SURGERY, WITH ABNORMAL REACTION/LATER COMPLICATION, NO SURGICAL MISADVENTURE E9912 INJURY DUE TO WAR OPERATIONS FROM BULLET
Principal Procedure *4574 RESECTION OF TRANSVERSE COLON
Other Procedures 5411 EXPLORATORY LAPAROTOMY 8628 NONEXCISIONAL DEBRIDEMENT OF WOUND/INFECTION/BURN 4523 COLONOSCOPY 4513 ENDOSCOPY OF SMALL INTESTINE 9604 INSERTION OF ENDOTRACHEAL TUBE 9671 CONTINUOUS MECHANICAL VENTILATION FOR LESS THAN 96 CONSECUTIVE HOURS
I certify that the narrative descriptions of the principal and secondary diagnoses and the major procedures performed are accurate and complete b the best d my knowledge.
Physician's Signature Date
MEDCOM - 5830
DOD 13042