Download ICD-10 Academic Testing Family Practice

ICD-10 Academic Testing
Family Practice
DESTINATION 10.1.2015
Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association
Family Practice – Scenario #1
Narrative Title: HCD-3
Narrative Desc: Holocarboxylase Deficiency
Patient Info:
Age: 27
Height: 64
BP: 120/64
Resp-rate: 18
Gender: Female
Weight: 120
Pulse: 70
Temp: 98.6
Chief Complaint: Patient in for weekly B12 injection.
Past Med. History: Member has history of holocarboxylase synthetase deficiency, no other medical history.
Office Visit Notes: Patient given 1000 mcg Vitamin B 12 Intramuscular in her left deltoid for holocarboxylase synthetase
deficiency. Patient tolerated injection without complications, and patient to return to office in one week.
Drugs: Vitamin B12
The following ICD-9 Code(s) were chosen:
269.2
266.2
279.2
281.3
270.9
The following ICD-10 Code(s) were chosen:
E56.9
E53.8
E81.818
D51.1
D81.818
Family Practice – Scenario #2
Narrative Title: HHD 2
Narrative Desc: Hypertensive Heart Disease
Patient Info:
Age: 44
Height: 62
BP: 152/92
Resp-rate: 20
Gender: Female
Weight: 155
Pulse: 84
Temp: 98.4
Chief Complaint: Patient seen in office with complaints of headache and shortness of breath
Past Med. History: Patient has history of HTN and is sometimes non-compliant with her medications. She is prescribed Capoten 50 mg BID, but she often
takes it only once daily or "forgets." She takes Crestor 10 mg daily for high cholesterol and she also has smoked 1 pk/cig./day x 30 years.
Office Visit Notes: Patient states that she has been having headaches intermittently and feels likes she is more short of breath than usual. She has had some
swelling in her feet at times and also feels very tired. Upon examination, member has +1 pedal edema, but lungs are clear. Heart exam shows-RRR, NML
S1, S2 and no new murmurs and pulse ox was 98% on room air. Chest X-ray normal. Member states that her last dose of Capoten was last night and that she
has to refill her prescription. B/P was 152/92. Advised Patient to start taking medication as directed and gave her a sample of Capoten to take until she
refills her prescription. Encouraged Patient to adopt a healthier lifestyle, including a diet to restrict her salt intake to less than 2 grams daily, and to consider
quitting smoking. Prescription written and referral to cardiologist was made for hypertensive heart disease without heart failure. Patient to follow-up in
office after seeing Cardiologist in 1 month.
Drugs: Capoten, Crestor
The following ICD-9 Code(s) were chosen:
401.9
782.3
403.10
402.9
V65.3
784.0
786.05
305.1
401.2
The following ICD-10 Code(s) were chosen:
I11.9
010.91
I15.9
E78.0
Z71.3
R51
R06.02
643.00
Z71.6
G43.C0
R60.0
Z72.0
Family Practice – Scenario #3
Narrative Title: LCA 1
Narrative Desc: Liver Cancer
Patient Info:
Age: 51
Height: 70
BP: 138/75
Resp-rate: 16
Gender: Male
Weight: 250
Pulse: 70
Temp: 98.7
Chief Complaint: Patient is complaining of abdominal pain and swelling and appearing jaundiced.
Past Med. History: Patient has no past surgical history. He has been obese all of his adult life. He was diagnosed as a type 2 diabetic in 2010. He was diagnosed
with hepatitis C when he was 10.
Office Visit Notes: A thorough history and physical was performed. Of note skin and conjunctiva are jaundiced. Patient has been nauseous with no appetite and
losing weight. Palpation of the liver shows it to be enlarged and hepatic bruit can be heard. He states his stools have been chalky white. Prior to the visit
patient obtained bloodwork and alpha-fetoprotein indicates liver disease. In combination with current signs and symptoms hepatocellular cancer is diagnosed.
Imaging studies will confirm diagnosis.
Drugs: None
The following ICD-9 Code(s) were chosen:
155
789.0
250.00
571.9
782.4
278.00
070.54
787.02
789.1
783.21
070.51
155.2
070.70
The following ICD-10 Code(s) were chosen:
R17
R11.0
R10.84 B17.10
C22.7
C22.8
B18.2
E66.9
E11.9
R63.4
R16.0
K76.9
C22.0
B18.1
B63.4
Family Practice – Scenario #4
Narrative Title: HTN 2
Narrative Desc: Hypertension
Patient Info:
Age: 35
Height: 70
BP: 180/85
Resp-rate: 16
Gender: Male
Weight: 165
Pulse: 72
Temp: 98.0
Chief Complaint: Patient presents today with headache. Patient has been monitoring blood pressure at home and it has been elevated.
Past Med. History: Patient was diagnosed as hypertensive 5 years ago and has been on Benicar. He initially started on a 5 mg dosage, but one year ago that
was increased to the 20mg dosage daily. Otherwise this is a healthy active male. There have not been any past surgeries or injuries.
Office Visit Notes: Blood pressure in the office remains elevated standing, sitting and laying down. No papilledema on eye exam. Will increase dosage to
40mg daily. Counseled patient on diet, including salt reduction and exercise. Patient to follow up in 6 weeks to evaluate revised dosage of medication.
Drugs: Benicar
The following ICD-9 Code(s) were chosen:
401.9
401.01
V65.3
784.0
402.1
The following ICD-10 Code(s) were chosen:
I10
Z71.3
I11.9
E51
Family Practice – Scenario #5
Narrative Title: HCK-1
Narrative Desc: Hypertensive Chronic Kidney Disease
Patient Info:
Age: 64
Height: 70
BP: 160/100
Resp-rate: 20
Gender: Male
Weight: 220
Pulse: 84
Temp: 98.4
Chief Complaint: Patient seen in office with complaints of shortness of breath and swelling in the feet
Past Med. History: Patient has history of HTN and takes Zestril 30 mg qd, high cholesterol and takes Crestor 10 mg qd, smokes 1 1/2 packs of cigarettes/day.
Office Visit Notes: Patient states that he has been short of breath and has noticed swelling in his feet recently. Upon examination, member has +1 pedal edema
but lungs were clear and Chest X-ray was negative. Patient has + Proteinuria and GFR of 70 ml/minute. B/P was 160/100. Zestril dosage increased to 40
mg. qd and Lasix 20 mg qd as well as Cozaar 25mg qd. was added. Encouraged Patient to adopt a healthier lifestyle, by walking daily and to consider
quitting smoking. Patient instructed on a Low Sodium diet, advised to do daily weights and to call the office if there is a 2-3 pound weight gain or more
within 24 hours and/or with increased shortness of breath. Prescriptions written and referral to Nephrologist was made for Hypertensive Chronic Kidney
disease. Patient to follow-up in office after seeing Nephrologist in 1 month.
Drugs: Zestril, Crestor, Lasix, Cozaar
The following ICD-9 Code(s) were chosen:
403.9
782.3
791.0
404.92
403.1
272.0
786.05
V65.3
403
The following ICD-10 Code(s) were chosen:
I12.9
N18.9
J12.9
Z72.0
R60.0
R80.9
010.21
Z71.3
R06.02
E78
E78.0
E87.0
I15
I15.9
Family Practice – Scenario #6
Narrative Title: PIL 1
Narrative Desc: Pain in limb
Patient Info:
Age: 53
Height: 64
BP: 130/70
Resp-rate: 16
Gender: Female
Weight: 125
Pulse: 70
Temp: 98.6
Chief Complaint: Patient is being seen today for pain in her right great toe.
Past Med. History: Patient is up to date on all of her immunizations. She has no surgical history. She is having normal menses. No other medical conditions
present.
Office Visit Notes: Patient stubbed her toe against her dresser when she got up during the night to go to the bathroom 2 days ago. Toe is painful to touch, but
not broken per x-ray. Patient told to take Ibuprofen for the pain and to keep it elevated and iced when possible.
Drugs: Iibuprofin
The following ICD-9 Code(s) were chosen:
729.5
759.7
718.48
The following ICD-10 Code(s) were chosen:
M79.609
M79.674
W22.03A
M76.6
M79.656
M79.67
Family Practice – Scenario #7
Narrative Title: LNC 2
Narrative Desc: Lymphedema Non-Infectious Channels
Patient Info:
Age: 62
Height: 54
BP: 130/74
Resp-rate: 20
Gender: Female
Weight: 150
Pulse: 84
Temp: 98.6
Chief Complaint: Patient complains of chronic pain and swelling of the right arm.
Past Med. History: Patient has a history of a right total mastectomy with lymph node removal 2 years ago for breast cancer. Chemotherapy and radiation was
given and Patient is now in remission. HTN and takes 30 mg. Zestril qd and high cholesterol for which she takes Crestor 10 mg. qd. She is a non-smoker.
Office Visit Notes: Patient is a new referral for chronic right arm lymphedema secondary to a total mastectomy and lymph node removal for breast cancer.
Patient states that she has anywhere from +2 to +4 edema depending on the activities that she does. Today, she presents with +3 edema of the right arm,
hand and fingers. Patient was fitted with a compression stocking and also was prescribed a pneumatic compression pump to be applied at night and during
the day as needed for severe edema. Patient will follow-up with her own doctor in 1 month and will return here if there are any problems with the fit of her
compression stocking as needed.
Drugs: Zestril, Crestor
The following ICD-9 Code(s) were chosen:
457.1
174.9
457
401.9
272.0
457.0
V16.3
The following ICD-10 Code(s) were chosen:
I97.2
I89.0
Z85.3
C44.501
189.0
Family Practice – Scenario #8
Narrative Title: OPU 1
Narrative Desc: Opioid Dependence, unspecified
Patient Info:
Age: 38
Height: 63
BP: 138/70
Resp-rate: 16
Gender: Female
Weight: 126
Pulse: 70
Temp: 98.7
Chief Complaint: Patient is complaining of withdrawal symptoms from oxycodone.
Past Med. History: Patient has been using oxycodone for 6 months for pain relief following an auto accident that caused injury to her back and neck. She was
prescribed 10 mg every 4-6 hours as needed and has been taking 4 to 6 tablets daily. She had been healthy up to that point, with no previously diagnosed
medical conditions and no surgical history other than delivery of two children.
Office Visit Notes: Patient realizes she is too dependent on the oxycodone and so has decided to stop taking the drug. Her last dose was yesterday. She is
experiencing chills, tachycardia, restless leg syndrome weakness and generalized restlessness. Patient is being prescribed Buprenorphine as a replacement
and to wean her off the oxycodone. Patient will be started with Buprenorphine 16mg/Naloxone 4mg daily dose. Patient will return in 2 weeks. Suggested
patient attend therapy or 12 step program to discuss the addiction behavior.
Drugs: Oxycodone, Buprenorphine, Naloxone
The following ICD-9 Code(s) were chosen:
304
292.0
E929.0
723.1
304.90 724.8
333.94
785.0
780.64
The following ICD-10 Code(s) were chosen:
F11.20
11.23
515.9
F11.23
S15.9
M54.9
M54.2 Z71.51
R68.83
R00.0 G25.81 V49.9 F00.23
Family Practice – Scenario #9
Narrative Title: PRE 2
Narrative Desc: Pre-Surgical Exam
Patient Info:
Age: 55
Height: 70
BP: 148/85
Resp-rate: 20
Gender: Male
Weight: 255
Pulse: 77
Temp: 98.6
Chief Complaint: Patient being seen today for pre-surgical exam and blood work.
Past Med. History: This obese male has had no previous surgical history. He has hypertension for which he is taking Zestril 30mg daily and type 2 DM for
which he is taking Metformin 500mg BID. He is taking Crestor for his high cholesterol, 10 mg daily.
Office Visit Notes: Patient is having a rotator cuff repair due to a golf injury he suffered 2 weeks ago. Surgeon requested clearance due to multiple health
issues. There are no significant abnormalities on exam except for the changes in his shoulder. Baseline EKG done in the office showed no abnormalities.
Patient will obtain blood work today, including HgbA1C to determine if blood sugar is well controlled and will not impact his healing process. Patient
counseled on maintaining strict diet and taking medications. Exercise will be determined by surgeon so as not to adversely impact healing. Patient also
instructed on importance of deep breathing exercises. Upon receiving results of labs, will notify patient and surgeon if surgery will be allowed. Patient also
already has the list of medications to avoid and what to take prior to surgery.
Drugs: Zestril, Metformin, Crestor
The following ICD-9 Code(s) were chosen:
V72.84
718.81
V72.83
840.4
401.9
272.0
272.4
278.0
401.1
250.00
V72.63
The following ICD-10 Code(s) were chosen:
Z01.818
545.80
Z10.818
S46.009
V93.53
I15.9
E78.0
E66.9
Z01.81
I10
E11.9
E78.5
S45.80
Z01.812 S46.01
Family Practice – Scenario #10
Narrative Title: LYM 1
Narrative Desc: Lyme Disease
Patient Info:
Age: 17
Height: 64
BP: 120/70
Resp-rate: 16
Gender: Female
Weight: 110
Pulse: 72
Temp: 98.6
Chief Complaint: Patient being seen today for the vaccine for Lyme disease.
Past Med. History: Patient has had no remarkable history of illnesses or surgeries and has been seen at this office since an infant. She is up to date on all other
immunizations.
Office Visit Notes: Patient and her mother are requesting the Lyme disease vaccine since she will be working in the forest during the summer. Vaccine given in
left upper arm per patient's request. Patient and mother received information as to possible adverse effects and instruction to call office if any of these
conditions should occur.
Drugs: Lyme Disease vaccine
The following ICD-9 Code(s) were chosen:
88.81
V05.9 V70.5
V03.89
The following ICD-10 Code(s) were chosen:
A69.20
Z23
Z02.1
Family Practice – Scenario #11
Narrative Title: HDF 1
Narrative Desc: Hypertensive Heart Disease with Heart Failure
Patient Info:
Age: 58
Height: 62
BP: 152/92
Resp-rate: 20
Gender: Female
Weight: 155
Pulse: 84
Temp: 98.6
Chief Complaint: Patient seen in office with complaints of shortness of breath and swelling of the feet.
Past Med. History: Patient has history of HTN and is sometimes non-compliant with her medications. She is prescribed Capoten 50 mg bid, but she often takes it
only once daily or "forgets." She takes Crestor 10 mg daily for high cholesterol and she also has smoked 1 pk/cig./day x 30 years.
Office Visit Notes: Patient states that she is more short of breath than usual. She has had quite a bit of swelling in her feet that gets worse as the day goes on and also
feels very tired. Upon examination, member has +3 pedal edema and rales are heard in her lungs. Cardiac exam reveals a regular rate and rhythm with an S3,
pulse ox is 95% on room air. Chest X-ray shows fluid in the bases bilaterally. Member states that her last dose of Capoten was last night and that she has to refill
her prescription. B/P was 152/92. Advised Patient to start taking medication as directed and gave her a sample of Capoten to take until she refills her prescription.
Prescriptions written for treatment of hypertensive heart disease with heart failure: Lasix 40 mg twice daily, Lanoxin .25 mg daily and K-Dur 20 meq daily.
Discussed with patient the need to restrict salt intake to 1500 mg daily and restrict fluid intake. Encouraged Patient to adopt a healthier lifestyle through diet and
exercise and to consider quitting smoking. Patient also advised to obtain daily weights and to call the office if there is a 2 -3 pound weight gain in 24 hours. A
referral to cardiologist was made for Hypertensive heart disease with heart failure. Patient advised to go to the ER if she develops chest pain or worsening of her
shortness of breath. Patient to follow-up in office after seeing Cardiologist in 1 month or if symptoms worsen.
Drugs: Capoten, Crestor, Lasix, Lanoxin, K-Dur
The following ICD-9 Code(s) were chosen:
404
782.8
786.05
402.90
305.1
402.91
402.01
428
402
782.3
428.9
272.9
V65.3
402.11
780.79
The following ICD-10 Code(s) were chosen:
I13.10
M79.89
R06.02
I11.0
I17.200
I110.0
I50.9
E87.0
E78.0
Z71.3
Z71.6
F17.209
I11.9
R53.83
Family Practice – Scenario #12
Narrative Title: IPV 1
Narrative Desc: Influenza due to other identified influenza virus with unspecified type of pneumonia
Patient Info:
Age: 64
Height: 69
BP: 142/80
Resp-rate: 20
Gender: Male
Weight: 180
Pulse: 84
Temp: 100.6
Chief Complaint: Pt complains of low grade fever, cough, muscle aches and tiredness for the last two days.
Past Med. History: Patient has a history of HTN and takes 40 mg of Zestril qd. He also takes Crestor 10 mg daily for high cholesterol. Patient is a non-smoker
and otherwise healthy.
Office Visit Notes: Patient seen in the Emergency room for cough and low grade fever of 101 for the past two days. His cough is sometimes productive of a
small amount of mucus. He thought that he had the flu, but he continued to feel worse and has now developed a fever. Chest X-ray showed pneumonia and
based on clinical examination this appears to be due to the influenza virus. Patient was prescribed Tamiflu and advised to drink plenty of fluids and get a lot
of rest and to take Tylenol or ibuprofen as needed for body aches. He will follow-up with his internist in 1 week or sooner if symptoms worsen.
Drugs: Zestril, Crestor, Tamiflu, ibuprofen, Tylenol
The following ICD-9 Code(s) were chosen:
487.1
487
488.81
780.60
786.2
780.79
401.9
272.0
The following ICD-10 Code(s) were chosen:
J10.1
J11.00
J10.00
I10
E78.0
R50.9
R52
R53.83
J14
J10.01
Family Practice – Scenario #13
Narrative Title: ACP-1
Narrative Desc: Chronic obstructive pulmonary disease with (acute) exacerbation
Patient Info:
Age: 57
Height: 69
BP: 142/80
Resp-rate: 28
Gender: Male
Weight: 180
Pulse: 84
Temp: 98.6
Chief Complaint: Patient seen in office with complaints of shortness of breath.
Past Med. History: Patient has a history of HTN and takes 40 mg of Zestril qd. He also takes Crestor 10 mg daily for high cholesterol. Patient has a history of
COPD and is supposed to take Advair daily but he ran out and is waiting for his mail order refills to arrive. He has an Albuterol inhaler and a home
nebulizer which he has used every 4 -6 hours as needed without improvement. He has a 40 year history of smoking 2 packs of cigarettes/day and still
smokes.
Office Visit Notes: This patient is known to me. He is seen today for an acute exacerbation of COPD. He states that he has not received any relief from his
Albuterol inhaler and has been using it every 3 hours instead of every 4 hours without relief. He states that he is out of his Albuterol nebulizer solution and
needs it refilled. Lung sounds are clear but diminished bilaterally. Chest X-ray is clear. Oxygen saturation was 96% on room air. A breathing treatment was
administered in the office with some relief. Patient was prescribed a Medrol dose pack and a refill was written for Advair and the Albuterol solution to get at
a local pharmacy. Patient was advised to take treatments every 4 hours and to follow-up in the office in 1 week or sooner if symptoms get worse.
Drugs: Zestril, Crestor, Advair, Albuterol, Medrol
The following ICD-9 Code(s) were chosen:
496
491.21
785.06
401.9
272.0 305.1
786.05
493.22
The following ICD-10 Code(s) were chosen:
J44.9
J44.1
I10
E78.0
F17.200 J44.0
I15.9 Z72.0
Family Practice – Scenario #14
Narrative Title: DMN 2
Narrative Desc: Type 2 diabetes mellitus with diabetic Neuropathy, unspecified
Patient Info:
Age: 60
Height: 67
BP: 140/78
Resp-rate: 20
Gender: Female
Weight: 180
Pulse: 82
Temp: 98.6
Chief Complaint: Patient complains of numbness, tingling and shooting pains in feet
Past Med. History: Patient has Type 2 DM and takes insulin 70/30, 40 units Q AM, also takes Crestor 10 mg. daily and
Zestril 30 mg daily for HTN
Office Visit Notes: This is patient is known to me. She has had IDDM for the last 15 years. Her last HgA1C was slightly elevated at 9 and her blood sugars
have been somewhat elevated at home. She comes today with complaints of numbness and tingling along with shooting pains in the feet that worsen as the
day goes on. Upon examination it is determined that patient has Type 2 DM with diabetic neuropathy based on decreased sensation to touch and heat and
cold. Encouraged Patient to adopt a healthier lifestyle by trying to walk 15-20 minutes daily, adhere to her 1800 ADA diet. Advised Patient that if blood
sugars get higher than what her internist recommended, that she should follow-up with him/her for possible dosage adjustment. Prescribed Lyrica 50 mg,
three times daily (baseline kidney functions were all normal). Will follow-up with patient in 2 weeks.
Drugs: Insulin, Crestor, Zestril, Lyrica
The following ICD-9 Code(s) were chosen:
250.92
250.4
250.20 250.60
357.2
250.62
355.8
401.9
272.0
250.9
250.6
250.00
The following ICD-10 Code(s) were chosen:
E11.8
R20.0
E11.40
E11.41
I15.9
E78.0
E11.43
E44.10
Z79.4
E11.14
E11.21
Family Practice – Scenario #15
Narrative Title: DMH-1
Narrative Desc: Type 2 Diabetes Mellitus Hyperglycemia
Patient Info:
Age: 51
Height: 67
BP: 140/78
Resp-rate: 20
Gender: Female
Weight: 180
Pulse: 82
Temp: 98.6
Chief Complaint: Patient complains of blurry vision and high blood sugars
Past Med. History: Patient has Type 2 DM and takes insulin 70/30, 40 units Q AM, also takes Crestor 10 mg. daily and Zestril 30 mg daily for HTN
Office Visit Notes: This is patient is known to me. She has had IDDM for the last 15 years. She comes today with complaints of blurry vision and high blood
sugars. She said that her blood sugars have been running anywhere from 240 - 280 consistently for about 2 weeks. Her HgA1C is 10 and her RBS in the
office is 265. To treat her Type 2 DM with hyperglycemia, her insulin dosage was increased to 50 units Q AM and 10 units at Q PM. She was instructed to
take her blood sugars before meals and at bedtime for 2 weeks and to follow-up in the office at that time or sooner if she has any other issues with her blood
sugars. Encouraged pt. to adopt a healthier lifestyle by trying to walk 15-20 minutes daily, adhere to her 1800 ADA diet.
Drugs: Insulin, Crestor, Zestril
The following ICD-9 Code(s) were chosen:
250.2
250.8
250.02
251.2
401.9
272.0
250
250.9
250.52
790.29
The following ICD-10 Code(s) were chosen:
E11.65
H53.8
E11.649
I15.9
E78.0
Z79.4
Family Practice – Scenario #16
Narrative Title: TET 1
Narrative Desc: Tetanus Vaccination
Patient Info:
Age: 59
Height: 60
BP: 152/85
Resp-rate: 16
Gender: Female
Weight: 145
Pulse: 70
Temp: 98.7
Chief Complaint: This is a new patient who came to the office for a check up and continuing her treatment for her hypertension. She is also requesting a tetanus
booster.
Past Med. History: Patient is new to the area and this office. She has had hypertension and is on Zestril 30mg daily. She is negative
for a surgical history.
Office Visit Notes: Patient came to the office for evaluation and continued treatment for her hypertension. Full history taken and nothing remarkable noted. Her
BP continues to be high even on medication. Medication is being changed to Lisinopril 40mg every morning to try to bring down the BP. Patient had also
requested a tetanus vaccine booster, which was administered.
Drugs: Zestril, Lisinopril, tetanus booster
The following ICD-9 Code(s) were chosen:
V06.5
401.9
V065
V03.7
The following ICD-10 Code(s) were chosen:
Z23
I10
A35
I11.9
Family Practice– Scenario #17
Narrative Title: HVP-1
Narrative Desc: Hemorrhage of
Vascular Prosthetic Devices, Implants and Grafts, Initial Encounter
Patient Info:
Age: 64
Height: 59
BP: 100/68
Resp-rate: 20
Gender: Male
Weight: 175
Pulse: 88
Temp: 98.6
Chief Complaint: Patient presented to the E.R. with hemorrhaging at his AV Fistula site.
Past Med. History: Patient has a history of Type II Diabetes and is on Dialysis three times a week. He takes Atenolol 15 mg daily, Lasix 40 mg daily, Aspirin
81 mg. daily, Calcichew tabs before meals, Alpha Calcidol, Iron 1 tablet daily and Insulin 20 U NPH daily and sliding scale insulin coverage with regular
insulin every 6 hours.
Office Visit Notes: Patient presented to the E.R. with hemorrhaging at his AV Fistula site. He had a towel around his arm and despite his wife applying constant
pressure the wound continue to bleed. He said that he just had dialysis earlier in the a.m. and that there had been some seepage of blood that scabbed over.
He then bumped his arm in the same spot and it started bleeding profusely. He said that his doctor has been talking about creating a new fistula as this one is
"getting old". Towel was removed and direct pressure was applied with a gloved fingertip. Lidocaine was injected at the site and a figure eight stitch at the
puncture site was completed. CBC and Coagulation studies were drawn and reported to patient's vascular surgeon. The patient was able to walk and move
around without further bleeding after about 1 1/2 hours. Patient was discharged and is to follow-up with his vascular surgeon tomorrow.
Drugs: Atenolol, Lasix, Aspirin, Calcichew, Alpha Calcidol, Iron, Insulin, Lidocaine
The following ICD-9 Code(s) were chosen:
996.74
996.0
250.0
909.3
447.0
250.40
585.9
996
The following ICD-10 Code(s) were chosen:
T82.838A
R58
E11.29
T82.538S
I77.0
E11.22 Z99.2
T82.43
T82.339A
T82.838
Family Practice– Scenario #18
Narrative Title: ODW-1
Narrative Desc: Opioid Dependence with Withdrawl
Patient Info:
Age: 22
Height: 70
BP: 140/80
Resp-rate: 22
Gender: Male
Weight: 150
Pulse: 100
Temp: 98.6
Chief Complaint: Patient presents to the Emergency room with complaints of Heroin withdrawal.
Past Med. History: Patient has a history of Heroin addiction for the past 2 years, he denies any other history except for childhood asthma which he has not
taken any medication for several years and he had a prior opiate addiction in which he obtained the medications from relatives without their knowledge.
Office Visit Notes: Patient presents to the Emergency room with severe Heroin withdrawal. He states that as a teen, he was addicted to Vicodin, which
progressed to using Oxycontin, that he was stealing from a relative who was prescribed it for back pain. He found that it was cheaper to purchase Heroin on
the street, so for the past 2 years, he has been injecting Heroin on a daily basis. He has been living with friends as he has been kicked out of his parent's
house due to his addiction. He doesn't have a job or a means to support his habit, so he has been without Heroin for over 48 hours. Upon examination,
Patient has dilated pupils, severe abdominal cramping, nausea, vomiting and diarrhea. Patient was given Buprenorphine 10 mg for the withdrawal
symptoms and Clonidine 0.1 mg every 4-8 hours prn. Social work was consulted to check on availability of treatment centers. Patient is currently stabile
and his vitals signs have improved.
Drugs: Buprenorphine, Clonidine
The following ICD-9 Code(s) were chosen:
292
292.0
304.0
304.1
304.01 304.00
292.00
The following ICD-10 Code(s) were chosen:
I19.939
F11.23
F11.10
Family Practice– Scenario #19
Narrative Title: CHK-1
Narrative Desc: Hypertensive Heart & Chronic Kidney Disease
(without heart failure, with stage 1 through stage 4 chronic kidney
disease, or unspecified chronic kidney disease)
Patient Info:
Age: 37
Height: 70
BP: 150/90
Resp-rate: 20
Gender: Male
Weight: 180
Pulse: 84
Temp: 98.6
Chief Complaint: Patient states that he just doesn't feel well and has a lack of energy and decreased appetite
Past Med. History: Patient has a history of hypertensive heart disease and juvenile diabetes. Patient is a non-smoker and is current with all immunizations.
Patient currently takes 20 mg. of Zestril daily and NPH insulin 30 in the morning and 10 at night. He also takes Crestor 10 mg. daily
Office Visit Notes: This Patient is known to me. He presents to the office stating that he doesn't feel well, is very tired and has a lack of appetite. Physical
exam shows +1 edema to the lower extremities. Blood work and urinalysis reveal chronic kidney disease (CKD). GFR is 70 mL/minute, indicated Stage 2
CKD. Talked to the Patient about the importance of monitoring both blood sugar levels and blood pressure. B.P. was elevated in the office so increased the
Zestril dosage to 30 mg. qd. Lungs are clear, Chest x-ray negative, at this point no sign of heart failure. Impression is hypertensive heart disease with Stage
2 CKD. An echocardiogram will be ordered. Increased Zestril to 30 mg. daily and added Cozaar (prescription written). Spoke with Patient regarding
adopting a healthier lifestyle, such as walking more and watching his diet. Patient agrees that he needs to make changes. Further explained that this could
mean dialysis in the near future. Patient pamphlets were given to the Patient to read and he will follow-up in the office after the echocardiogram.
Drugs: Zestril, Crestor, Cozaar
The following ICD-9 Code(s) were chosen:
403.0
585.9
250.01
272.0
404.9
404.1
780.79
783.0
782.3
403.90
404
783.8
585.2
The following ICD-10 Code(s) were chosen:
I13.0
I13.10
I13.00
N18.2
N18.9
R60.0
R63.0
R53.83
I29.29
E10.29
I12.9
E10.22
E87
E78.0
21