Question
Same day, surgery- what are the ICD 10 codes? how do you breakthese down? could some let me know? greatly apperciate it. This is a
Same day, surgery- what are the ICD 10 codes? how do you breakthese down? could some let me know? greatly apperciate it.
This is a 75-year-old white female presenting with arecent increase in size of her thyroid gland on the right side. Itgives her trouble swallowing but is otherwise asymptomatic forthyroid disease. She has had a thyroid mass for many years. Thereis no family history of thyroid disease. Thyroid scan shows a largenodule, and ultrasound reveals that the mass is mostly solid butwith some cystic component. She is euthyroid. Past medical historyis positive for coronary artery disease with angina, recentcataract surgery on the left eye, congestive heart failure,hypertension, and adult-onset diabetes mellitus. Medications:Isordil 20 mg by mouth every 6 hours, propranolol 80 mg by mouthevery 6 hours, hydrochlorothiazide 100 mg by mouth 4 times daily,Nitro-Bid paste 1½ inch every evening, nitroglycerin 0.4 milligramssublingual as needed, Valium 10 mg by mouth 3 times daily. Noallergies. No smoking. No ethanol use. REVIEW OF SYSTEMS: Positivefor two-pillow orthopnea, nocturia times 2; occasionally paroxysmalnocturnal dyspnea and edema, none recently, however. Dipstickreveals 1 to 21 sugar in urine. The patient has lost about 25pounds on the recent diet. Physical: HEENT: Left cataract removed,right eye with cataract, thyroid not inflamed. Neck: Supple,thyroid enlarged on right side extending to isthmus. Left sidefeels normal. Lungs: Clear. Breasts: Benign. Heart: Regular ratewith positive S4, no murmur heard. Abdomen: Protruberant umbilicalhernias, soft, nontender, no masses. Extremities: No edema, pulses21 and symmetrical and no focal motor or neurological deficits.Impression: Thyroid nodule. On 4/13, the patient was taken to theoperating room where she underwent subtotal thyroidectomy for herenlarged thyroid. Frozen section diagnosis was nodular thyroidtissue consistent with follicular adenomas. She underwent thesurgery well and did well in her postoperative course. Bloodpressure was 130/80. She will be discharged today on herpreadmission medications. She will be seen by Dr. Numann byappointment. DIAGNOSES: Thyroid follicular adenoma.Hypertension._______________________________________________________________________________________
22.The patient was admitted with gross hematuria following along duration of prostatic symptoms and intermittent hematuria forseveral days. After the insertion of the Foley catheter anddrainage of 400 cc of grossly bloody urine, chemistry testsrevealed that he was in chronic renal insufficiency with a BUN of66. His urinary output was very adequate. IVP showed poorlyfunctioning kidneys but enough also to show an elevation of thebladder floor consistent with enlarged prostate (benign).Cystoscopy was carried out to rule out other causes of hematuriaand the bladder found to be heavily trabeculated with manydiverticuli and again a large prostatic gland. DIAGNOSES: Chronicrenal insufficiency. Bladder diverticula. Benign prostatichypertrophy._______________________________________________________________________________________
23.This 17-year-old white female was admitted to the hospitalwith the chief complaint of a past history of recurrent bouts oftonsillitis, having missed three days of school this year becauseof a severe bout and having another sore throat that started assoon as the penicillin stopped. She also has had earaches. She hashad streptococcal sore throats. She consulted Dr. Port, who advisedher to have a T&A. Physical examination revealed the tonsils tobe large, but they appeared benign at the time of admission. Shehad an anterior lymphadenopathy. Laboratory studies on admissionrevealed hemoglobin 13.3 grams,
ematocrit 39.6, and white blood count 5700 with 42 polys.Urinalysis was negative. The bleeding time was 1 minute 30 seconds.Partial prothrombin time was 24 seconds. Chest x-ray normal. Thepatient was admitted to the hospital, prepared for surgery, andtaken to the operating room where, under satisfactory generalendotracheal anesthesia, a T&A was performed. Following theoperation, she had an uncomplicated postoperative recovery. Thatafternoon she was awake, alert, and afebrile; had no bleeding; noanesthetic complications. The tonsillar fossa were clean; she isaccordingly discharged on April 13 to see Dr. Port in one week andme in two weeks. DIAGNOSES: Diseased and hypertrophied tonsils andadenoids. Past history of recurrent bouts of streptococcal sorethroats and tonsillitis.
24.This is a 15-year-old who was involved in a truck and bicycleaccident in August. He continued to have problems with his rightknee. He was referred to Dr. Jones, who diagnosed him as havingtorn medial meniscus of right knee as the sequela of previousfracture right patella and knee soft tissue injuries. Patient wasadmitted to the hospital on August 17 and underwent surgery thatconsisted of arthrotomy and medial meniscectomy of right knee.Patient did well on a postoperative period and was sent home ingood condition.DIAGNOSIS: Bucket-handle tear of medial meniscus,right knee. (Sequela.)
25.Two weeks ago on a routine examination, Dr. Woughter detecteda firm ridge in the right lobe of the prostate, became suspicious,and suggested to the patient that he have this biopsied at an earlydate. Patient presents now for biopsy procedure. A needle biopsy ofthe prostate reveals adenocarcinoma of prostate. Pathology resultsreport adenocarcinoma of prostate. I have advised a radicalprostatectomy. DIAGNOSIS: Carcinoma of prostate.
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