REASON FOR REFERRAL
Systemic lupus erythematosus.

HISTORY OF PRESENT ILLNESS
Patient was told she had SLE in 1998.

PAST HISTORY
Illnesses: Lupoid hepatitis, 1998.
Operations: Renal biopsy. Hepatic biopsy.

REVIEW OF SYSTEMS
HEENT: Conjunctivitis and iritis.
Cardiorespiratory: Pleuritic chest pain.
Gastrointestinal: Vague abdominal pain.
Extremities: Edema.

PHYSICAL EXAMINATION
GENERAL: The patient is a 50-year-old female with obvious pedal edema.
CHEST: Heart: RRR. Lungs: Clear. Breasts: Normal.
ABDOMEN: Hepatomegaly. No shifting dullness or fluid waves.
EXTREMITIES: There was 3+ pitting edema in both lower extremities.

DATABASE
Sodium 135, potassium 4.6, calcium 7.6, phosphorus 2.7, total protein 4.5, albumin 1.9, BUN 25, creatinine 1.1, uric acid 5.2. Hemoglobin 13.6, hematocrit 42.1, sedimentation rate 35. WBCs 5,600 with 86 segs, 0 bands, 12 lymphs, MCV 93. The 24-hour urine protein is 10.57 gm, creatinine 828 mg. Q-panel: The 5’-nucleotidase was elevated at 12.98, anti-DNA negative, anticentromere negative, anti-smooth muscle negative, ANA positive at 195, anticardiolipin antibody normal and mitochondrial antibody normal.

ASSESSMENT
1. Abnormal antinuclear antibody positive for lupus.
2. Nephrosis.

RECOMMENDATIONS
Nephrology consultation for evaluation of renal status.
ICD-10-CM:
ICD-10-CM:

Question

16-07-2022
Medicine

contestada

REASON FOR REFERRAL
Systemic lupus erythematosus.

HISTORY OF PRESENT ILLNESS
Patient was told she had SLE in 1998.

PAST HISTORY
Illnesses: Lupoid hepatitis, 1998.
Operations: Renal biopsy. Hepatic biopsy.

REVIEW OF SYSTEMS
HEENT: Conjunctivitis and iritis.
Cardiorespiratory: Pleuritic chest pain.
Gastrointestinal: Vague abdominal pain.
Extremities: Edema.

PHYSICAL EXAMINATION
GENERAL: The patient is a 50-year-old female with obvious pedal edema.
CHEST: Heart: RRR. Lungs: Clear. Breasts: Normal.
ABDOMEN: Hepatomegaly. No shifting dullness or fluid waves.
EXTREMITIES: There was 3+ pitting edema in both lower extremities.

DATABASE
Sodium 135, potassium 4.6, calcium 7.6, phosphorus 2.7, total protein 4.5, albumin 1.9, BUN 25, creatinine 1.1, uric acid 5.2. Hemoglobin 13.6, hematocrit 42.1, sedimentation rate 35. WBCs 5,600 with 86 segs, 0 bands, 12 lymphs, MCV 93. The 24-hour urine protein is 10.57 gm, creatinine 828 mg. Q-panel: The 5’-nucleotidase was elevated at 12.98, anti-DNA negative, anticentromere negative, anti-smooth muscle negative, ANA positive at 195, anticardiolipin antibody normal and mitochondrial antibody normal.

ASSESSMENT
1. Abnormal antinuclear antibody positive for lupus.
2. Nephrosis.

RECOMMENDATIONS
Nephrology consultation for evaluation of renal status.
ICD-10-CM:
ICD-10-CM:

Respuesta :

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lheduardomarques lheduardomarques · Answer 1 · 2022-07-18T17:38:38+02:00

In these cases the ICD-10 for this patient is ICD 10 - L93 Lupus ICD 10 N13. 2 Hydronephrosis with obstruction by renal and ureteral calculi.

1. Abnormal antinuclear antibody positive for lupus. - CID 10 - L93 Lúpus eritematoso

2. Nephrosis. ICD 10 N13. 2 Hydronephrosis with obstruction by renal and ureteral calculi.

What does the ICD mean?

The International Classification of Diseases and Related Health Problems, better known as the ICD, is one of the main epidemiological tools in everyday medical practice. The main function of the ICD is to monitor the incidence and prevalence of diseases, through universal standardization.

With this information, we can conclude that ICD-10 is the 10th revision of the International Statistical Classification of Diseases and Related Health Problems

Learn more about ICD-10 in brainly.com/question/27932590

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