icd 10 answer the following
Answer the following questions after listening to the video clip and reading the following case study. Discharge Summary Admitting Diagnosis: Unstable angina History: This 69 year old man was admitted through the ER with chest pain that began while he was eating his lunch. After lunch he went to do his grocery shopping and he began to develop discomfort in his chest and jaw. He drove himself to the ER. The ER physician admitted the patient due to unstable angina. Vital signs at the time of admission: BP: 140/60, Heart rate 110 to 120 Hospital Course: Cardiac enzymes- CPK of 105, Troponin- 4.7 with a relative index of 5.4 Digoxin level of 1.8 All other lab values were normal. EKG was positive for a new anterior wall infarction. The patient was maintained on Imdur 30 mg daily and metoprolol 50 mg in the morning and evening. The patient stabilized and refused to stay in the hospital for additional work-up. He was instructed to see me in seven days or to call an ambulance if symptoms reoccur. Discharge Diagnoses: Acute anterolateral transmural Q wave infarction Hypertension What is the correct ICD-10-CM diagnostic code(s) for this case?
I21.09, I10
Answer the following questions after listening to the video clip and reading the following case study. Office Note This 78 year old male returns to the office today to follow-up on diagnostic testing completed due to his ongoing muscle aches, myalgia, stiffness and muscle weakness. Laboratory testing:Urinalysis was positive for hemoglobin. The urine myoglobin test and serum myoglobin test were both positive. The serum CPK value was high.Following these values additional testing was completed that confirmed elevated muscle enzymes in the blood. Because of these findings a diagnosis of rhabdomyolsis was confirmed. Plan:I discussed with the patient the need for a short inpatient stay to start IV hydration, and diuretics and to monitor lab values. The patient agreed and will be admitted today. What is the correct ICD-10-CM diagnostic code(s) for this case?
M62.82
Answer the following questions after listening to the video clip and reading the following case study. Physician Office Note This 38-year-old male returns to the office today in follow-up. He and his wife have been attempting to conceive a child for 4 years. His wife has had excessive testing that has concluded there are no physiological reasons that she is unable to conceive a child. The patient presented to me 6 weeks ago for a consultation. After that visit he was sent for infertility testing. Today he and his wife are here to discuss the results of the testing. Patient History: The patient has a history of a malignant neoplasm of the eye for which he received chemotherapy 6 years ago. All other systems are noncontributory. Physical Examination:HEENT: Normal Heart: Within normal limits Genitalia: Normal developed 38-year-old male. No abnormalities noted. Rectal Exam: Deferred at this time Laboratory Findings: Semen analysis shows an abnormally low sperm count of 12 million/mL. Assessment:Diagnosis: Male infertility. At this time I cannot conclude whether this is due to past chemotherapy. Plan: This patient and his wife were referred to the Infertility Clinic at University Hospital for consultation. He was advised to follow up with me on an annual basis or as needed. What is the correct ICD-10-CM diagnostic code(s) for this case
N46.9, Z85.840, Z92.21
Answer the following questions after listening to the video clip and reading the following case study. Physician Office Note This 15 year old male patient presents today to monitor his congenital stenosis of the inferior vena cava.He has been asymptomatic. The stenosis was first noticed when he underwent a chest X-ray to evaluate a possible injury after a chest trauma one year ago. He also had an ultrasound completed that confirmed the diagnosis. Vital Signs B/P 120-80, Temperature 98.6, Weight 155 pounds ECG: Taken today is normal. HEENT: Normal Lungs: Clear Heart: Normal rate and rhythm. Abdomen: Soft, no masses noted. Extremities: Reflexes within normal limits. There is no evidence of varicose veins or other abnormalities at this time. Plan: It was explained to the patient and his patients that many patients with stenosis of the inferior vena cava develop chronic venous insufficiency and deep vein thrombosis. Because of this I am scheduling the patient for compression ultrasonography with color Doppler assessments and helical computer tomography . The findings from this test will determine if additional imaging is necessary and if the patient needs to be placed on any anticoagulant therapy or other medications or therapy regimen.The patient will return to my office after completion of the testing. What is the correct ICD-10-CM diagnostic code(s) for this case?
Q26.0
Answer the following questions after listening to the video clip and reading the following case study. Physician Office Note: This 54-year-old white female presents to the office today with a chief complaint of abdominal pain for 3 days. She is also experiencing indigestion for which she has been taking over-the-counter antacids.Allergies: The patient is allergic to Cipro.Review of Systems: The patient is complaining of abdominal pain without nausea and vomiting. There is no chest pain or shortness of breath reported by the patient.Physical Examination:HEENT: No findingsHeart: RSR without murmur Neck: Supple. No massesExtremities: No findings Lungs: ClearAbdomen: The patient complained of increased discomfort when the abdomen was palpated. No masses noted.Assessment and Plan: This is the third time that the patient has been in my office in the last 3 weeks complaining of this discomfort. The feeling of indigestion has been controlled by the over-the-counter antacids. I am ordering an abdominal ultrasound to rule out any gastritis. Patient should schedule this within the next 2 to 3 days. Patient was placed on a bland diet until the ultrasound can be obtained. Patient should be seen following the ultrasound. What is the correct ICD-10-CM diagnostic code(s) for this case?
R10.9, K30
Answer the following questions after listening to the video clip and reading the following case study. Physician Office Note:This 15-year-old female patient was playing softball and attempted to catch a ball and fell on her right shoulder 2 days ago. She then presented to the emergency room and an x-ray was obtained; at that time the x-ray showed no fractures. She was referred to me for follow-up. Patient History:There is no significant medical history for this patient. Physical Examination:HEENT: NormalHeart: Within normal limitsExtremities: The right shoulder is painful to touch, and there is limited mobility at this time. There are no other findings noted.Skin: There are no breaks in the skin at the sight of the right injury. There are no other findings. Assessment:Diagnosis: Right shoulder sprain and pain Plan:This patient should continue to ice the shoulder and rest the shoulder for the next 5 to 6 days. She was instructed not to play softball at this time. What is the correct ICD-10-CM diagnostic code(s) for this case?
S43.401D
Answer the following questions after listening to the video clip and reading the following case study. Emergency Department Note Katy presented to the ED at 5:00 a.m. very flushed with difficulty breathing, chest tightness and tachycardia. She is using her accessory muscles for breathing. There is audible wheezing. A pulmonary function test showed a decrease in FEV. A chest x-ray showed hyperinflation and bronchial wall thickening. Diagnosis: acute exacerbation of asthma. Treatment: Two nebulizer treatments were administered. After 12 hours of observation she was sent home when her breathing was stabilized. She is to follow-up with her primary care provider in one week. What is the correct ICD-10-CM diagnostic code(s) for this case?
J45.901
Answer the following questions after listening to the video clip and reading the following case study. Emergency Department Note This 26 year old pregnant female presented to the emergency department. At the time of admission she was experiencing crampy abdominal pain. She stated that at home she had passed a considerable amount of blood. She is also having vaginal bleeding at this time. She states it has been 8 weeks since her last menstrual period. Diagnosis: spontaneous abortion What is the correct ICD-10-CM diagnostic code(s) for this case?
O03.9
Answer the following questions after listening to the video clip and reading the following case study. Physician Office Note John Jones, a three week old infant, returns to the office today with his parents to follow up on diagnostic testing. Following delivery it was noted that there was prolonged bleeding from the umbilical cord of the infant and after circumcision. The initial level of fibrinogen in the venous blood was found to be below normal range. The following tests were completed and all were found to be abnormal: bleeding time, partial thromboplastin time, prothrombin time, Reptilase time and thrombin time. A congenital fibrinogen deficiency test was then ordered and the results were discussed today. The child appears in no acute distress and all vital signs are within normal limits. Skin: On the left arm there is a bruised area. Also on both legs there are bruised areas. Abdomen: Soft and nontender Heart: Normal rate and rhythm Results from Testing: The congenital fibrinogen deficiency test confirmed congenital afibrinogenemia. Plan: The parents were informed of the test results and the condition was discussed with them stressing the importance of ongoing monitoring of this condition. The patient will be referred to University Hospital Hematology to be monitored. Diagnosis: congenital afibrinogenemia What is the correct ICD-10-CM diagnostic code(s) for this case?
D68.2
Answer the following questions after listening to the video clip and reading the following case study. Inpatient Discharge Note This 10 year-old male patient is a type 1 diabetic. He was admitted from the emergency room because he was in a coma with ketoacidosis. During his hospitalization his insulin levels were adjusted and he is stabilized at this time. He was instructed to follow up with me in the office in one week or sooner if needed. Diagnosis: type 1 diabetes with ketoacidosis with coma What is the correct ICD-10-CM diagnostic code(s) for this case?
E10.11, Z79.4
Answer the following questions after listening to the video clip and reading the following case study. Patient Name: Sam Floor Skilled Nursing Facility Note:This 72-year-old male patient is complaining to the nursing staff that his scalp and the middle of his chest are irritated and itch. Allergies: The patient has no known allergies. Review of Systems: This 72-year-old patient was admitted to this facility 2 years ago due to dementia. Physical Examination:HEENT: No findingsHeart: RSR without murmurNeck: Supple with thyroid in the midlineSkin: The skin of the scalp and chest appear inflamed and red and are covered with yellow greasy appearing scales. Seborrheic dermatitis is present.Lungs: ClearAbdomen: Soft and nontender Plan:I have instructed the nursing staff to apply hydrocortisone cream to the scalp and chest areas for 5 days. What is the correct ICD-10-CM diagnostic code(s) for this case?
L21.9
Answer the following questions after listening to the video clip and reading the following case study. Inpatient Physician's Progress Note This two day old infant examined today to follow up after the results of diagnostic tests. Blood Gas: Study indicates reduced oxygen tension and ineffective gas exchange. Chest X-ray: presence of infiltrate Infant continues to exhibit signs of infant respiratory distress syndrome, type 2. Orders: Continue titrated oxygen and aerosol infusion of Survanta. What is the correct ICD-10-CM diagnostic code(s) for this case?
P22.1
Answer the following questions after listening to the video clip and reading the following case study. Office Visit Note This 13 week pregnant patient is being seen today for supervision of her first pregnancy. She states that she feels well and has no complaints or symptoms of complications at this time. Weight from last visit was 130 pounds. Vital Signs- B/P: 130/80, temperature 98.8, weight on this visit is 132 pounds Lungs: Clear Abdomen: Measurement change is minimal from last visit. Fetal Heart Rate: A fetal Doppler was used to listen to the fetal heart rate which is within normal limits. What is the correct diagnostic code(s) for this case
Z34.01, Z3a.13
Answer the following questions after listening to the video clip and reading the following case study. Office Note This 84 year old patient presents today with a compliant of acute loss of hearing, tinnitus and pain in her left ear. Vital Signs: B/P 130/80, Weight 194 pounds Ear: Inspection of the right ear has no findings Inspection of the left ear reveals impacted cerumen in the ear. Mineral oil was placed in her ear and then the ear was irrigated and the wax removed. Hearing was normal. What is the correct ICD-10-CM diagnostic code(s) for this case?
h61.22
Answer the following questions after listening to the video clip and reading the following case study. Emergency Department Note This 48 year old woman is brought to the emergency department today by her mother. This patient is profoundly retarded which is complicating the examination. The mother states that the patient has had bouts of hypoglycemia and she is not eating well today. The patient is very "low on energy" per mother. Vital signs: B/P: 120/85, Temperature 99.8 Weight: 160 pounds HEENT: Normal Abdomen: Soft, nontender and no masses noted. Lungs: Clear Blood sugar was taken and found to be 45. The patient was started on IV as I felt this is the most advantageous manner in which to raise the blood sugar due to the patient's mental deficient. Blood sugar was then again taken and rose to 90. Patient's mother was given information about hypoglycemia and instructed to follow up with the patient's primary care provider as soon as possible. Diagnosis: hypoglycemia, treatment impacted by profound mental retardation What is the correct ICD-10-CM diagnostic code(s) for this case?
E16.2, F73
Answer the following questions after listening to the video clip and reading the following case study. Inpatient Discharge Summary History of Present Illness:This patient is 76 years old with a known history of cancer of the lung with metastasis to the brain. The brain neoplasm is present at this time. Cancer of lung was resected 6 months ago and there is no evidence that it is present at this time. The patient was admitted because his daughter noticed him getting weaker and because he was not eating or drinking well for the last two days. He has undergone chemotherapy and radiation in the past 5 months, and he asked for the treatment to be stopped. Upon examination at the time of admission, he was dehydrated and weak due to lack of eating. Hospital Course: The patient requested that he receive care only for his dehydration. He was given IV hydration and refused all other treatment. Medications at Discharge: The patient was discharged on Vicodin for pain, 1 every 4 hours as needed for pain. Discharge Diagnoses: Dehydration, metastatic cancer to the brain, history of lung cancer. What is the correct ICD-10-CM diagnostic code(s) for this case?
E86.0, C79.31, Z85.118
Answer the following questions after listening to the video clip and reading the following case study. Inpatient Visit Physician Note S: This 92 year old male patient was admitted two days ago due to a sudden onset of fever, headache and complaining of a very stiff neck. The patient took Tylenol at home to relieve his headache but it did not relieve the headache. When his fever reached 101 his daughter brought him to the emergency department and he was admitted. Testing confirmed meningitis. O: Respirations are 32. Pulse is 100 BP: 130/90. He is alert and in some pain at this time. LUNGS: Clear, no wheezing present. HEENT: WNL. Heart: Normal sounds. Abdomen: Soft and nontender. A: Results from a cerebral spinal tap confirm meningitis due to streptococcus pneumoniae. P: Due to the patient's age he will remain in the hospital for a course of IV antibiotics for approximately two more days. What is the correct ICD-10-CM diagnostic code(s) for this case?
G00.1
Answer the following questions after listening to the video clip and reading the following case study. Office Note This 39 year old male presents today because of pain in his right leg that occurs at night. He describes this as a cramping feeling. He states that he has not injured his leg in the past. EXAM: HEENT: Normal Lungs: Clear Extremities: Normal to touch and neurological testing. ROM normal. I instructed him to heat his leg prior to going to bed and offered to give him a referral to PT at this time. He stated he wanted to try at-home exercises first. Since this is only occurring at night when sleeping, I feel that this is sleep-related leg cramps. What is the correct ICD-10-CM diagnostic code(s) for this case?
G47.62
Answer the following questions after listening to the video clip and reading the following case study. Office Note This 69 year old male presents to the office today complaining of an irregular floating spot in his left eye and blurred vision. Ophthalmoscope Examination: Examination revealed no findings in the right eye. In the left eye there is a separation of the inner layers of the retina with fluid in the subretinal space. There is also retinal break. Assessment: retinal detachment with retinal break Plan: patient will be scheduled for surgery What is the correct ICD-10-CM diagnostic code(s) for this case?
H33.002
Answer the following questions after listening to the video clip and reading the following case study. Physician Office Hematology Note:This 63-year-old white male presents today to review laboratory findings. He cut his hand 3 weeks ago, and the wound bled for a considerable amount of time. He was referred to me from this primary care provider. Blood work was ordered at that time. Laboratory Findings:Abnormal prothrombin time Allergies:The patient has no known allergies. Review of Systems:This patient was treated 5 years ago for anemia. Physical Examination:HEENT: No findingsHeart: RSR without murmurNeck: SuppleExtremities: The wound has healed.Lungs: ClearAbdomen: Soft and nontender Assessment and Plan:This patient has an abnormal prothrombin time that needs to be investigated further.I am ordering additional testing to rule out vitamin K deficiency. Patient will be scheduled for follow-up after testing results are obtained. What is the correct ICD-10-CM diagnostic code(s) for this case?
R79.1, z86.2
