A+ GUARANTEED PASS
IMPRESSION:
1 Anterior and posterior chest wall contusion.
2 Right shoulder injury.
(Report codes for the definitive diagnosis.)
PLAN: Discharge home. Return for new or worsening symptoms.
Sling for comfort.
What diagnosis code(s) are reported?
Q03.9
CASE 6
PREOPERATIVE DIAGNOSIS: Congenital hydrocephalus.
POSTOPERATIVE DIAGNOSIS: Congenital hydrocephalus.
,CLINICAL HISTORY: The patient is a 2-month-old boy who was born
and was IUGR. He did well for the first several weeks; however, he
then developed a large head. Mom noticed full fontanelle arid in the
last week or so, and they have noticed the eyes have decreased
mobility. He tends to stare straight and has some trouble looking up
and even to the sides bilaterally, so she reported it to her
pediatrician. Pediatrician ordered a CT scan and referred the patient.
I saw the patient yesterday in clinic. We ordered an MRI; MRI was
done this morning. Initial read shows the congenital hydrocephalus;
however, it is not a Dandy-Walker. We had a discussion with the
family about risks, benefits, potential complications and also
different procedures. We talked about a third ventriculostomy
however, given the patient's age and the fact was hydrocephalus, he
has elected to go with the shunt, Family is comfortable with this and
will bringing him to the OR today for shunting.
What diagnosis code(s) are reported?
O47.02, Z3A.25
CASE 7
HPI: 20-year-old female, estimated gestational age 25.3 weeks, who
presents with red staining after wiping with toilet paper this
afternoon. No abdominal pain. Contractions: Negative. Fetal
Movement: Present.
ROS:
, Constitutional: Negative.
Headache: Negative.
Urinary: Negative.
Nausea: Negative.
Vomiting: Negative.
Past Medical/Family/Social History:
Medical History: Negative.
Surgical History: Negative.
Social History: Alcohol: Denies. Tobacco: Denies. Drugs: Denies.
EXAM:
General Appearance: No acute distress.
Abdominal: Soft. Non-tender.