Scenarios for ICD 10 ; 9 – Flashcards

Established 50-year-old patient with end-stage renal disease, currently receiving dialysis, is seen for acute left upper quadrant pain. Chapter 3, ICD 10

Patient is seen for unstable angina. He has a history of arteriosclerotic coronary artery disease. Chapter 3, ICD 10

Patient is seen for follow-up for hypertension. He has end-stage renal disease. Chapter 3, ICD 10

Following outpatient surgery for a right bunionectomy for hallux valgus, the patient was admitted to observation due to an exacerbation of her asthma post procedure. Chapter 3, ICD 10

Patient presents with a fracture of the right femur shaft due to a fall from her horse while riding, initial encounter. Chapter 3, ICD 10

A patient who smokes 2 packs of cigarettes per day and suffers with chronic pulmonary disease is seen in follow-up for acute bronchitis. Chapter 3, ICD 10

Patient was scheduled for outpatient surgery for right inguinal hernia repair; however, he has a fever and a URI and the procedure is canceled. Chapter 3, ICD 10

Chronic osteomyelitis with draining sinuses of right first toe due to methicillin susceptible Staphylococcus aureus. Chapter 4, using ICD 10

Pathological fracture of the left femur, due to neoplastic disease, initial encounter. Chapter 4, ICD 10

Type I diabetes mellitus with unspecified diabetic retinopathy and with diabetic cataract. Chapter 5, ICD 10

Hypertensive congestive heart failure with hypertension and chronic kidney disease, stage IV. Chapter 5, ICD 10

Chapter 6, ICD 10 PREOPERATIVE DIAGNOSIS: Left renal calculus. POSTOPERATIVE DIAGNOSIS: Same. PROCEDURE PERFORMED: Left ESWL (extracorporeal shock wave lithotripsy). CLINICAL NOTE: This gentleman came in with renal colic, a stent was placed. He presents now for ESWL. The patient was given a general laryngeal mask anesthetic, prepped and draped in the supine position. Stone targeted and shock head engaged. A total of 2,400 shocks at maximum KV and stone partial fragmentation and dissolution could be seen. The patient tolerated the procedure well and transferred to the recovery room in good condition. He will be seen in follow-up in two weeks time for KUB.

streptococcal group B arthritis of the metacarpus and phalanges, left hand. Chapter 6, ICD 10

An established patient is seen in follow-up for coronary artery disease. Patient is also a diabetic on oral medications. The patient had a coronary artery bypass graft 6 months ago. Labs were reviewed and prescriptions for diabetic medications were renewed. Chapter 9, ICD 9

Patient is seen by internist for medical Clearance for inguinal hernia repair. The patient has a number of chronic medical conditions including hypertension, diabetes type 2, and atrial fibrillation. Chapter 9, ICD 9

Established patient presents with dyspnea and lower extremity edema. The physician determined that the patient's symptoms were due to an exacerbation of congestive heart failure. Chapter 9, ICD 9, text review

Patient was admitted as an outpatient for an arthoscopic knee procedure to repair old anterior cruciate ligament tear. Chapter 9, ICD 9 Text review

Status post cardiac pacemaker placement. Chapter 9 Exam

Adjustment of a colostomy tube for fitting. Need answer, not in workbook, chapter exam or midterm Chapter 9

Personal history of peptic ulcer. Chapter 9, exam

Dysphagia due to previous cerebrovascular accident - Chap 10 text review #20

What is the code for respiratory syncytial virus, RSV? Chap 10 text review #21

Gastroenteritis due to Norwalk virus? Chapter 10 workbook #20

Steptococcal Phayngitis

Impending respiratory failure

Adenocarcinoma of the upper-outer quadrant right breast with metastasis to the axillary lymph nodes. Chap 11, text example

Arteriosclerotic dementia with delirium. Chapter 11 This is an example of using manifestation first

Chapter 11, chapter exam PREOPERATIVE DIAGNOSIS: Mass, right breast. POSTOPERATIVE DIAGNOSIS: Mass, right breast. OPERATIVE PROCEDURE: Right breast mass excision. PROCEDURE: With the female patient under general anesthesia, the breast and chest were prepped and draped in a sterile manner. An elliptical incision was made in the central portion of the breast about the palpated mass, including the area of the nipple. This was excised all the way down to the fascia of the breast and then submitted for frozen section. Frozen section revealed a carcinoma of the breast with what appeared to be a good margin all the way around it. We then maintained hemostasis with electrocautery and proceeded to close the breast tissue using 2-0 and 3-0 chromic. The skin was closed using 4-0 Vicryl in a subcuticular manner. Steri-Strips were applied. The patient tolerated the procedure well and was discharged from the operating room in stable condition. PATHOLOGY REPORTED LATER INDICATED: Primary, malignant neoplasm.

Malignant hypertensive heart disease, with heart failure. Chapter 11, workbook #34

ASHD of native coronary artery and COPD Chapter 11, workbook #49

Bacteremia due to pseudomonas Chapter 11, wb#52

Malignant ascities, primary site unknown. Chapter 11, #54

Alcoholic delirium tremens due to dependence on alcohol. Chapter 11,#56

Type 2 diabetes mononeuropathy of the legs. Chapter 11, wb#62

cardiac insufficiency 6 months after coronary artery bypass surgery. Chapter 11, wb#66

Mrs. Smith is at 32 weeks' gestation and is admitted with sever bleeding with abdominal cramping. An emergency ultrasound is done and fetal monitors are applied. She is diagnosed with total placenta previa with indications of fetal distress. An emergency cesarean section is done, with delivery of a viable male infant.

Scenario regarding surgery after traumatic open fracture accident on page 367

Patient is lethargic with severe abdominal cramping and vomiting following an accidental ingestion of 5 tablets of Tylenol with codeine and a bottle of vodka. There are 9 codes for this case:

PREOPERATIVE DIAGNOSIS: Excess skin of the right heel./Bulky free flap. POSTOPERATIVE DIAGNOSIS: Same. SURGICAL FINDINGS: 10.5 x 8.5 cm area of redundant fat of flap of right heel. PROCEDURE PERFORMED: Defatting of flap of right heel with excision of redundant skin (benign). ANESTHESIA: General endotracheal anesthesia. POSITION: Prone. ESTIMATED BLOOD LOSS: Negligible. DESCRIPTION OF PROCEDURE: The patient was intubated and turned into prone position. The right foot and lower leg were prepped with Betadine scrub and solution and draped in the routine sterile fashion. The medial aspect of the flap was elevated excising the old scar in the process, and the flap was elevated to about 60% of its extent to include all of the redundant fat that was within the flap. We removed about 1.5 cm thickness of flap from the bottom of the flap and left a layer of padding of about a cm on the bed. Hemostasis was secured, and then we closed the wound with a combination of plain 3-0 Prolene and horizontal mattress sutures and some horizontal half mattress sutures of 3-0 Prolene. We dressed the wound temporarily with Kerlix and Kling. Dr. Miller will then proceed with his portion of the procedure.

Sally, a 16-year-old, was lighting a bonfire in the backyard of her home when she sustained the following burns: Second-degree (1%) and third-degree burns—left upper arm (5%): First-degree burn—left anterior leg (9%): Total body surface: Caused by: Place of occurrence:

Preoperative examination for a patient who will receive a renal transplant due to ESRD, currently on dialysis. Progress Exam 1 - ICD 10

Patient is admitted for radiation therapy for metastatic bone cancer, primary unknown. Patient develops severe vomiting secondary to the course of radiation and is kept an extra day for stabilization. I9

INDICATION: Septic Shock due to severe sepsis and the need to initiate mechanical ventilation. PROCEDURE PREFORMED: Elective intubation. ANESTHESIA: Versed and fentanyl PROCEDURE: After the procedure was explained to and consent was obtained. . . . Prog exam 1, ICD 10

Preoperative Examination for elective cholecystectomy due to gallstones. Patient is seen by a pulmonologist because of COPD - I9

Arteriosclerosis of native arteries of the left leg with gangrene. - I10

Dysphagia, oropharyngeal phase, due to previous stroke. I9

Malignant hypertension with Stage IV chronic kidney disease. ICD 10