Health Information Management: ICD-10-CA / CCI Coding 2022

Patient 1

Name: Wilsok, Lori, 35 years old (Female), Surgical Day Care

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Admitting Record Details

Admitting diagnosis: Incision and drainage (I and D) nose abscess.

Most Responsible Diagnosis: Nose abscess.

Diagnosis/indication for surgery:

This woman presented for nasal surgery. She had undergone surgical treatment 3 to 4 weeks ago and had done well. She unfortunately developed a subcutaneous abscess at the tip of her nose and therefore, was brought to the operating room.

Anesthesia used: General.

Description of procedure:

Under general anesthesia we made an incision and drained the abscess and irrigated the region with bacitracin and betadine. She will be maintained on antibiotics orally for the next week.

Patient 2

Name: Young, Lori, 64 years old, (Female) Surgical Day Care

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Consultation request details:

Summary of relevant history: The patient is scheduled to have excision of face lesion and also facelift and a neck lift.

Impression: In summary Mrs Young is a woman with questionable cardiac murmur.

Admission Record Details

Admitting Diagnosis: Facial lesion.

Most Responsible Diagnosis:

1. Aging face. 2. Neck lipoma. 3. Focal lesion. 4. Deviated septum.

Surgery/ Diagnostic Interventions: Facelift. Excision lipoma neck. Septoplasty. Excision focal lesion.

Operative Note (Provider) Details

Diagnosis/indication for surgery: This woman presents for facial surgery, she has a submental mass consistent with possible lipoma. She also has a large cutaneous lesion on the right cheek region, she believes this has increased in size. She finally also complained of a deviated septum and was booked for elective surgical treatment. Her final complaint was that of aging face and ptotic neck with central dehiscence of her platysma, which is causing her symptoms and asked that this could be corrected at the same time as excision of the submental mass. Therefore arrangements for a neck-plasty and face lift were made.=

Anesthesia used: General.

Procedure name: Facial surgery.

Description of procedure: She was placed under general anesthesia. Standard face lift incisions performed in front of the tragus. We elevated subcutaneous tissue anteriorly and inferiorly and centrally exposing the entire facial soft tissue. Inferiorly we stayed superficial to the platysma muscle and superiorly we were in the subcutaneous plane above the SMAS. SMAS plication performed with a #3-0 Ethibond suture and submental mass was excised through a submental incision and sent for pathology, it looked to be consistent with a lipomatous mass. The central dehiscence of the platysma was brought together with Ethibond suture as well and 4-0 Vicryl. Redundant skin was trimmed and incisions closed with 5-0 fast absorbing gut and 5-0 Prolene suture and staples to the scalp. A cutaneous lesion on the right cheek was excised and sent for pathology, and turbinate reduction and anterior septoplasty was also performed under local anesthesia where a small spur of her septum was resected. The patient tolerated the procedure, no complications, and was awoken after all appropriate dressings placed.

Pathology Report Details

PREOPERATIVE DIAGNOSIS: Facial lesion.

POSTOPERATIVE DIAGNOSIS: Facial lesion.

SPECIMEN SOURCE: A. Lipoma neck. B. Biopsy lesion from right cheek.

GROSS EXAMINATION:

A. Received in formalin is a yellowish-red fatty tissue mass measuring 3.5 x 2.8 x 1.2 cm. Specimen is serially incised and a representative section is submitted for microscopy in 1 block.

B. Received in formalin is a single whitish-tan soft tissue fragment measuring 0.4 x 0.4 x 0.3 cm. All taken for microscopy in 1 block.

DIAGNOSIS: A. Lipoma neck: Lipoma. B. Biopsy lesion right cheek: Papillary intradermal nevus.

Patient 3

Name: Dwens, Carolyn, 4 years old (Female) Inpatient

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Admission Record Details: Provisional Diagnosis: Gastrointestinal bleed

History and Physical (Provider Details)

Chief Complaint (CC):

A 5-1/2-year-old female with history of type 1, ANA positive pauciarticular juvenile rheumatoid arthritis, taking Naprosyn and Plaquenil, presents with history of 2 vomiting episodes this a.m. (the second of which had blood clots in it) accompanied by epigastric abdominal pain.

History of Present Illness (HPI):

This patient was reportedly well yesterday and no complaint; the patient crawled into bed with parents this a.m. complaining of abdominal pain; Mom gave the patient grape Tylenol. The patient vomited (looked grape color); soon after the patient vomited a second time, this time the parents noticed numerous large blood clots in vomitus; no frank blood; the parents brought the patient to hospital.

Past Medical History (PMH):

Pregnancy: No bleeding, no infections, no PIH, no DDM. Delivery: Term (38 weeks), spontaneous vaginal delivery, (mom G1, P0). Neonate: Required BVM ventilation, cord around neck, Mom does not recall Apgar scores, recovered well, however. Devel: Consistently 90th percentile weight, 80 percentile height. No concerns regarding milestones/development, currently in kindergarten. Diagnosis of pauciarticular JRA type 1 ANA positive affecting knees (onset symptoms 10 months ago): 1. Followed by Rheumatology 2. Originally started on Naprosyn, then Methotrexate x5 weeks, but medication poorly tolerated. 3. Steroid injection into knees beginning 7 months ago, were very helpful. 4. Effusions noted in knees last month, started on Plaquenil 100 mg daily. 5. Iridiocyclitis, prednisone eye drops.

Review of Systems (ROS):

Constitutional:

No appetite until last evening, "picked at dinner". No recent infection, no change in diet, no diarrhea, no constipation, no urinary symptoms, no energy until this a.m. No other bleeds, no bruising.

Neurological:

Fundi normal, PERRL, EOM normal, Tone normal, DTRs equal bilaterally. Alert and oriented.

Medications: Immunizations are up-to-date including varicella. Plaquenil 100 mg since last month. Naprosyn 150 mg b.i.d for past 7 months, upped dose since early last month. The patient was on prednisone eye drops x6 weeks, finished last week.

Assessment: A 5-year-old female with past history of pauciarticular JRA on Naprosyn and Plaquenil with epigastric pain and evidence of blood in vomit today. UGIB likely PND secondary to long term NSAID use. DIFFERENTIAL DIAGNOSIS: UGI bleed: 1. PUD secondary to NSAID. 2. PUD, H. pylori. 3. Mallory-Weiss tear (unlikely). 4. Vomitus may not have had blood in it, also unlikely since Mom is a nurse. In this case vomitus due to viral gastroenteritis.

Plan: 1. Presumed UGIB: Differential diagnosis as above, likely secondary to NSAID/PUD or duodenal. CBC, electrolytes, BUN, PT/PTT baseline plus reassess this eve. Admit, vitals every hour including postural assessment. Hold NSAIDs. Give PPI (Losec). Type and screen for possible transfusion requirement. GI consultation, ? need for: H. pylori testing, triple therapy, endoscopy, UGI study. Start IV. 2. JRA: Contact rheumatologist for advice (do not want to trigger relapse). As above hold Naprosyn, and no acute problem currently. Mild past steroid use, probably not need stress dose, want to avoid due to UGIB anyway. 3. Disposition: NOA to family doctor. Observe overnight for hemodynamic status, further bleeding. Probable DC on PPI, maybe switch to COX2 inhibitor.

Rheumatology assessment: Thank you for asking me to see this patient re: NAIDs while she is hospitalized for investigation and management of upper GI bleed.

She was diagnosed with JRA 7 months ago. Her only joint involvement has been both knees. She has been treated with Naproxen, intra-articular corticosteroid injections, short course of methotrexate and Plaquenil. She has had intermittent hematuria. She has no clinical features to suggest scleroderma.

I agree with the differential diagnoses cotemplated so far. However, because she has a very specific antibody associated with scleroderma, I am concerned about possible gastrointestinal telangiectasia that can be seen in scleroderma.

I suggest it would be helpful to know the etiology of the GI bleed. I have spoken with GI about possible endoscopy. Do Urinalysis, if RBC present, please consult Nephrology.

Day 1 Progress Note Details

GI Fellow: GI bleed fever epistaxis 1x vomit this morning - clear fluid no diarrhea epistaxis this a.m. miserable, flushed, not toxic looking; febrile Impression: febrile illness ?resp, ?RLL GI bleed - hemodynamically stable Plan: suggest consider CXR.

Day 2 Progress Note Details

Bleeding has stopped. Fever likely due to a viral illness since it occurred while on antibiotics Rheumatology saw and said disease is in remission but needs to start back on meds. GI doesn't want to scope patient as bleeding was likely due to NSAID or Mallory-Weiss tear. Patient should take food/fluids as tolerated and re-start meds. Discharge later today.

Discharge Summary Details

Admitting complaint: Gastrointestinal bleed.

Discharge diagnosis: Upper gastrointestinal (GI) bleed secondary to NSAID gastritis or Mallory Weiss tear.

Other Diagnoses: Fever, blood cultures negative. JRA treated with Plaquenil and Naproxen.

Course of care: Received IV pantoloc infusion x1 day, then oral omeprazole 20 mg p.o. b.i.d. x2 days and then daily, ceftriaxone IV for 2-1/2 days IG every 8 hours for fever.

Summary: She presented to hospital after vomiting blood clots. She developed a fever that afternoon. Blood cultures were sent and she received IV cefotaxime IG every 8 hours (160 mg/kg/day). She was also started on pantoloc infusion (0.2 mg/kg/hour) for 1-1/2 days and oral Losec 20 mg b.i.d. (2 mg/kg/day) x2 weeks then daily thereafter as long as she is on NSAIDs. Blood cultures negative. Normal GI, lung, and heart exam on discharge.

Discharge instructions: No NSAIDs, use Tylenol for pain, return if symptoms recur.

Discharge medications: Omeprazole tablets 20 mg p.o. b.i.d. x2 weeks, then once daily while continuing NSAIDs. Plaquenil 100 mg p.o. once daily.

Follow-up: Rheumatology clinic 2 to 3 weeks' time.