Question

1- Inpatient Visit Physician Note
S: This 92-year-old male patient was admitted 2 days ago due to a sudden onset of fever, headache, and complaining of a very stiff neck. The patient took Tylenol at home to relieve his headache but it did not relieve the headache. When his fever reached 101 his daughter brought him to the emergency department and he was admitted. Testing confirmed meningitis.O: Respirations are 32. Pulse is 100. BP: 130/90. He is alert and in some pain at this time.
LUNGS: Clear, no wheezing present.
HEENT: WNL.
Heart: Normal sounds.
Abdomen: Soft and nontender.
A: Results from a cerebral spinal tap confirm meningitis due to Streptococcus pneumoniae.
P: Due to the patient’s age he will remain in the hospital for a course of IV antibiotics for approximately 2 more days.

fill the blanks
What is the correct ICD-10-CM diagnostic code(s) for this case......x.......

What is the shape of streptococcus bacteria......x......

2-Inpatient Discharge Summary
History of Present Illness:
This patient is 76 years old with a known history of cancer of the lung with metastasis to the brain. The brain neoplasm is present at this time.
Cancer of lung was resected 6 months ago and there is no evidence that it is present at this time. The patient was admitted because his daughter noticed him getting weaker and because he was not eating or drinking well for the last 2 days. He has undergone chemotherapy and radiation in the past 5 months, and he asked for the treatment to be stopped.
Upon examination at the time of admission, he was dehydrated and weak due to lack of eating.
Hospital Course: The patient requested that he receive care only for his dehydration. He was given IV hydration and refused all other treatment.
Medications at Discharge: The patient was discharged on Vicodin for pain, 1 every 4 hours as needed for pain.
Discharge Diagnoses: Dehydration, metastatic cancer to the brain, history of lung cancer

fill the blanks
What is the correct ICD-10-CM diagnostic code(s) for this case.........x........ ,.......x......... ,......x........

What type of neoplasm is considered cancerous.....x.......

Cancer of the.....x....... tissue metastasizes through lymph tissue and blood.

Malignant neoplasms grow relatively rapidly and......x...... or spread to other body parts.

Answer 1

Answers

1. ☆ICD - 10- CM diagnostic codes

* G00.1 - Pneumococcal meningitis

☆Shape of streptococcus bacteria is spherical

2. ☆ ICD-10 - CM diagnostic codes

* Dehydration - E86.0

   * Metastatic cancer to the brain - C79.31

   * History of lung cancer - Z85.118

☆ Malignant neoplasms

   ☆Primary tissue

   ☆Metastasis