ICD-9 coding principles and applications

Advanced Nursing Practice

Advance Nursing Practice

Ignoring symptoms that are clearly indicative of something wrong is a bad idea. The idea becomes even more ill-advise as the symptoms become more and more prominent and/or numerous in nature. While chronic diseases and other disorders take time to do their work, waiting until they become unbearable is something that should never occur as the chances of an optimal outcome are not nearly as good as they could or should be. Further, become the opposite of a hypochondriac and avoiding the diagnosis and care of a doctor is also less than wise. For example, a person might think they have cancer when instead they just need a little modest medical care and lifestyle changes to their health back on track. Indeed, it would seem that precisely that is going on with the patient described and diagnosed below.

Patient Initials: Not Known Age: 60 Years Old Gender: Male

Subjective Data

Client Complaints

The patient has arrived and described a decrease in urinary flow and nocturia, the latter being the consistent and present need to get up to use the bathroom in the middle of the night. Patient thinks he has cancer and is seeking help because there have been some major and palpable problems over the last forty-eight hours.

History of Present Illness

Patient has apparently been experiencing these symptoms to some degree over the last two years. The patient is coming to the doctor now because the issue has apparently gotten much worse over the last fourteen days or so. The problem is not new but has ramped up in severity of symptoms over the last few weeks. Patient says there are no signs of abdominal pain or nausea. Patient also denies that there is blood in the stool. No gross hematuria but also has not had a positive review of symptoms in the past.

Past Medical History

The patient has been diagnosed and treated for a number of disorders but they have been mostly minor and are being treated. He recently had a possible case of angina. He was diagnosed with chest wall syndrome, was treated and released. There were no other issues with that disorder beyond that. Takes Cardizem (240 mg daily) and Zocor (20 mg daily) and is not known to be allergic to any particular drug. Per the drugs above and some other details, the patient is being treated for hypertension and hypercholesterolemia. No known history of heart disease with the patient but there is apparently some in the case of some distant aunts and unclesbut nothing direct to the patient per what was told for this report.

Social/Personal History

Patient does not smoke or drink, per history collected. Denies partaking in illicit drugs. His wife does all of the cooking of the house. So much as the patient knows, he eats healthy. He does get regular checkups but is apparently not telling his physician about his bladder/prostate issues if this is true. Patietn is Hispanic but was born in the United States and his social/personal circles are all within his immediate geographic vicinity. He lives in a suburban setting.

Patient's Support System

Patient has one brother and one sister. Both are still alive and are both in good health so far as they all know and admit. Patient also has two children that are grown, both in their mid-30's.

Description of Client's Support System

His wife provides the bulk of his personal support and there is no known dysfunction between the two. He also gets support from his coworkers. However, the patient is high-strung and over-achieving and this is probably a major contributory factor of his hypertension. However, he does not have overt stress in his life but he does not get much in the way of support from anyone outside his job or his work.

Behavioral or Nonverbal Messages

As noted before, he is very ambitious and his circle of trusted people is fairly small. Could be a sign of a social introvert but he seems well-adjusted despite this.

Client Awareness of Abilities, Disease Process, and Health Care Needs

Patient is certainly aware of the issues he is facing although he is almost certainly blowing them out of proportion. He obviously has ignorance about what his disorder likely is as well as the complexity of dealing with the same. He is verifiably not aware of the options and resources that exist for him to combat and address the issues he is having. This would include both the urinary issues he is having now as well as the heart procedure he had, his hypertension and so forth.

Objective Data

Vital Signs

BP = 140/92 -- Right Arm -- Sitting Down

Temp = 99 po

P = 80 and regular

R = 18 and is non-labored

Wt = 200 lbs

Ht = 71"

BMI = 27.90 (overweight)

Physical Assessment Findings

HEENT: WNL

Lymph Nodes: None

Lungs: Clear

Heart: RRR with grade III/VI systolic murmur that is best heard when along the right sternal border

Carotids: No bruits.

Abdomen: Android Obesity, non-tender.

Rectum & Genital/Pelvic: Stool is light brown, heme positive. Prostrate is boggy and tender to palpation

Extremities, Including Pulses: 2+ pulses throughout, no edema in the lower legs

Neurologic: Not examined

Lab Tests and Results

PSA: 6.0

CBC: WNL

Chem panel: WNL

Radiological Studies: None

EKG: None

ICD-9 Diagnoses/Client Problems:

Obesity, Unspecified (278.00)

Unspecified Essential Hypertension (401.9)

Neoplasm or Uncertain Behavior of Prostate (236.5)