assign the appropriate principal and additional diagnosis codes
Use the ICD-9-CM manual to assign the appropriate principal and additional diagnosis codes along wit Show more Use the ICD-9-CM manual to assign the appropriate principal and additional diagnosis codes along with the procedure code for the following case scenario. The patients visit to the clinic and ER admission are not coded. HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old right-handed male who presents with a 4-day history of severe right-sided headache visual blurring and diplopia. The patient was seen in the ENT clinic for discharge from his right ear of 2 days duration diagnosed to be otitis externa on the day of admission. The patient was subsequently transferred from the clinic to the emergency department. The patient denied a history of seizure motor or sensory deficit nausea or vomiting trauma or speech difficulties. Past medical history of sinusitis for many years. Current medications are none. Allergies none. PHYSICAL EXAMINATION: HEENT: Right pupil 3 mm nonreactive. Left pupil 2 mm reactive. Disconjugate gaze present. Right ptosis. Oropharynx clear without lesions. The neck is supple without lymphadenopathy or thyromegaly. Heart: regular rate and rhythm without murmurs or gallops. Lungs clear to percussion and auscultation. The neurological examination: awake alert oriented times three follows three simple commands. Cranial nerves partial right third nerve palsy with ptosis 3-mm nonreactive right pupil right medial gaze with disconjugate extraocular eye movement. Motor is 5/5 throughout without drift. Finger test is within normal limits. The sensory is intact to fine touch and proprioception: cerebral examination within normal limits. HOSPITAL COURSE: Patient was admitted with suspicion of intracranial aneurysm. On the following day the patient underwent a three-vessel cerebral angiogram that demonstrated a posterior communicating artery aneurysm and questionable anterior communicating artery aneurysm. The patient underwent a right craniotomy for clipping of right posterior communicating artery aneurysm. Postoperatively the patient was observed in the surgical intensive care unit until his mental status was stabilized. The palsy and ptosis noted preoperatively resolved during the postsurgical course. The patient has been ambulating without resistance and tolerating food well. The patient was also seen by the ENT service during the hospitalization for his otitis externa and their recommendations were followed. FINAL DIAGNOSES: Right posterior communicating artery aneurysm; anterior communicating artery aneurysm; right otitis externa. a. 434.91 380.15 117.3 39.52 b. 442.89 380.22 88.41 c. 442.9 747.81 01.24 d. 437.3 380.10 39.51 Show less
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