What is the rationale for this case? What is the rationale for the ICD-10- codes for this case? HPI: 9 Yrs 2 Mos female established patient who presents to the office with compliants of throat pain and neck pain since yesterday afternoon. Better with motrin (12.5ml, last dose at 0630 this morning). Worse with sitting down or laying down. No abdominal pain. Has slight headache at base of head. No new rashes (follows with dermatology for eczema, given a cream last week when seen by dermatologist). No "fevers" but forehead feels "a bit hot" now. Decreased oral intake of solids but is doing well with liquids. Normal UOP. No known ill contacts but attends school. No trauma to neck but says base of neck hurts with flexion and extension of neck. Past Medical History: Past Medical History: UNSPECIFIED ASTHMA Eczema, followed by dermatology. Otherwise healthy. Past Surgical History: None. Allergies: No Known Allergies Immunizations: Immunizations Up to Date: Yes Medications: Motrin as needed for pain, albuterol as needed, no other medicines (stopped singulair and flovent about 6 months). Family History: No ill contacts Cardiac/Sudden Death: negative Diabetes: positive: grandparents, extended family members Asthma: negative Hematologic: not obtained/not obtainable Genetic: not obtained/not obtainable Social History: LAHW parents and sibs. Daycare or School: yes Smokers: no Review of Systems: Constitutional: HPI Eyes: negative ENT/Mouth: HPI CV: negative Respiratory: negative All others reviewed and are negative Pulse: 124 Temp: 37 °C (98.6 °F) Resp: 24 Weight: 48.4 kg Gen: Tearful but alert. Appropriately interactive on exam. Head: NCAT. Ears: TMs pearly gray bilaterally. Eyes: PERRL, conjunctivae normal. Nose: No rhinorrhea. Throat: Erythema of the posterior oropharynx with palatal petechiae and halitosis. Uvula midline. Mouth/Teeth: MMM, normal dentition. Tongue protrudes midline. Neck: Supple, no LAD. Full active ROM in all 6 directions with no spinal tenderness and no step-offs on exam. Negative Kernig. Negative Brudzinzki. CV: RRR. II/VI musical systolic murmur at left sternal border with no rubs and no gallops. 2+ radial pulses bilaterally with brisk capillary refill. Lungs: CTA bilaterally. No crackles. No wheezes. Abdomen: Soft, nontender, non distended. Back: Normal. GU: Deferred. Ext: Moves all extremities equally. Normal strength. No deformity. Neuro: Alert, appropriately interactive, sensation grossly intact. Normal coordination. Normal speech. Skin: Erythematous and flesh colored papules scattered over extremities sparsely. No sandpaper-like rash. No other rashes nor lesions. Assessment/Plan: 9yo F with throat pain. Exam and history consistent with viral illness vs. Strep throat. No meningitic signs on exam. Neck pain seems to be muscular in nature. - Rapid strep positive. - Amoxicillin 1g by mouth daily for 10 days. - Tylenol or Motrin as needed for pain. - Supportive care. Encourage fluids.
Rationale:
The patient complains of neck pain, throat pain and headache. On examination, it shows the absence of muscle rigidity of neck and shows no signs of meningitis. Throat infection shows positive for streptococcus.
ICD-10 CM code - J02.0
M54.2
Rationale:
The patient has a streptococcal infection in the throat. In ICD-10 J comes under the respiratory system and J02.0 indicates the streptococcal throat infection. This is the principal diagnosis of the patient. This can be treated with appropriate antibiotics. Neck pain is secondary, so it is also coded and treated with analgesics.
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