Next determine the ICD-9 classification (diagnoses). The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) is the official system used in the United States to classify and assign codes to health conditions and related information.
•Search term page to identify the codes applicable to the care plan. http://www.cms.gov/medicare-coverage-database/staticpages/icd-9-code-lookup.aspx
•This link will lead to an excel version of the latest codes: http://www.cms.gov/Medicare/Coding/ICD9ProviderDiagnosticCodes/codes.html
Genitourinary Clinical Case
A 60-year-old Hispanic male presents with the chief complaint of decreased urinary flow. The patient has been experiencing this over the past two years, but for the past two weeks, the symptoms have increased significantly. The current symptoms are similar to what he experienced in the past. However, for the past two weeks, he has had increased nocturia, with decreased strength of urinary flow and slight terminal dysuria. Patient has had no treatment in the past. The nocturia has been very troublesome over the past two weeks. Yesterday he had significant difficulty in starting his urine flow and this is interfering with daily activities. He needs to pass urine four to five times every night. He has been urinating frequently and always needs to know if there are bathrooms around.
Patient does not complain of any other radiating pain. He has had no treatment or diagnostic work up in the past, but now the symptoms have been increasing in severity. He believes he had a low-grade fever yesterday. The patient is not sure what is going on but thinks he may have cancer. He had significant obstructive symptoms two days ago. Gradual worsening of symptoms has compelled him to seek medical help now.
Patient has not sought any medical care for this problem to date. He is being treated for hypertension and hypercholesterolemia. There is no known history of heart disease, but he was hospitalized five years ago as a suspected case of angina. He was diagnosed with chest wall syndrome for which he was treated and then released. There are no recent hospitalizations and no surgeries.
Denies any other positive review of systems. Denies abdominal pain, nausea or vomiting. No blood in the stool. No gross hematuria.
Cardizem 240mg daily
Zocor 20mg daily
Patient is compliant with the prescribed regimen and knows why he is being treated.
No known drug allergies
Patient has a master’s degree in engineering and his income is $65,000.00 per year. Though the patient is educated, he lacks an understanding of resources available to him. Patient has no problems with finances. He has excellent access to healthcare, but most often does not utilize the services to the extent that is expected. He has an excellent health insurance coverage including a prescription plan.
Patient is married and his spouse has excellent general health. He has two grown-up sons who live with their own families. They are 35 and 37 years old, both alive and well. Although the patient has a master’s in engineering, his knowledge of healthcare is inadequate. He believes that he is generally healthy.
His perception of self-efficacy is adequate. He has very little stress. His support systems include his wife and friends from work who provide him with the required emotional support. There is no family dysfunction. The patient is high strung and an over achiever. He gets little from social support outside the home or work.
Patient is originally from United States. He lives in a suburban setting. His resources include his wife and the people he works with. Though there are other resources available to him, he is not sure what they are.
Smoking: Non smoker
Alcohol: Does not drink
Substance use: Denies substance abuse
His wife does most of the cooking. He believes that he gets adequate exercise, eats healthy, and maintains a regular checkup regime with his physician.
He is an engineer and has always done the same work.
He has one sister and one brother. Both are alive and well. There is a remote history of heart disease among his aunts and uncles.
Vital Signs: BP right arm sitting 140/92; T: 99 po; P:80 and regular; R 18, non-labored; Wt: 200#; Ht: 71”
Lymph Nodes: None
Heart: RRR with Grade II/VI systolic murmur heard best at the right sternal border
Carotids: No bruits
Abdomen: Android obesity, non-tender
Rectum: Stool light brown, heme positive. Prostate enlarged, boggy and tender to palpation.
Genital/Pelvic: Circumcised, no penial lesions, masses, or discharge.Testes are descended bilaterally, no tenderness or masses
Extremities, Including Pulses: 2+ pulse throughout, no edema in the lower legs.
Neurologic: Not examined
Lab Results/Radiological Studies/EKG Interpretation
Chem panel: WNL
Radiological Studies: None
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