Question

History of present illness: This 72-year-old female presented to the ENT clinic complaining of her current epistaxis for 7 days prior to admission. The bleeding usually occurred from the right nostril. She had no prior history of epistaxis and denied any rhinorrhea. congestion, or anemia. On admission, she also complained of weakness. Four days prior to admission, her hematocrit level was 35, and the night before her admission, her hematocrit level was 29 when measured at an outside hospital. Her past medical history was significant for rheumatoid arthritis. Her past surgical history included status post bilateral knee replacement and right hip replacement. Medications at the time of admission included prednisone, 2 mg PO b.i.d.. and aspirin, six to eight per day for the past several months. Allergies: none.

Physical examination: On physical examination at the time of her admission, she was afebrile. Her blood pressure was 114/70, and her pulse was 92. Examination of the head and neck was significant for nasal cavities, which were without lesions and without PhYSical bleeding Sites. the remainder of the head and neck examination was within normal limits. Her neck was normal with no jugular venous distention. The lungs were clear. The heart rate was regular, and heart rhythm was Without murmurs. the abdomen was soft without masses, and the extremities had no bruises, cyanosis, or edema.
Laboratory data and hospital course: The patient was admitted, and a right anterior nasal pack was placed. Serial hematocrit levels were also obtained. The night of her first day of admission, she required replacement of an anterior pack because of refractory bleeding. The day following her admission, she underwent transfusion with 2 units of packed red blood cells for a hemoglobin level of 8.
0n the second day of her admission, bleeding was noted around the anterior pack. For this reason, she was taken to the treatment room, where a posterior nasophafyngeal pack and a new anterior pack were placed. She was then transferred to the special care unit and monitored on the cardiac monitor and with pluse oximetry. The posterior pack was left in place for 2 days. At this time, a repeat episode of bleeding showed that her bleeding time had normalized from its previous elevated level. She wasobserved overnight for 1 day without a pack in place. The patient did well during this observation period without any further bleeding.
When it was confirmed that the patient had no further bleeding for 48 hours after pack removal and the hematocrit level was stable, she was discharged to home. She was instructed to follow-up with her private PhySician. She was also instructed to refrain from taking aspirin and to use Disalcid 750 mg t.i.d., instead, for her arthritic pain. She was also placed on iron supplements 300 mg three times a day and told to continue using saline and Prenaris nasal drops.
Final diagnosis: Epistaxis.
Additional diagnosis: Rheumatoid arthritis.
1 Principal diagnosis:
2. Other diagnoses:
3. Principal procedure:
4. Other procedures:
5. Conditions to clarify with physician:

Need Help ICD-10-CM codes with POA indicator aassignment when required, ICD-10-PCS codes.

Answer 1

Principal diagnosis:   Despite of knowing the history of the patient, it was diagnosed that the physical conditions of the patient were normal, her heart rates and pulse rates were also normal. Although the patient denied any kind of allergy, yet the epistaxis indicates that an over dose of aspirin was taken by the patient. Due to overdose of aspirin the patient has excessive bleeding.

Another diagnosis: Although the patient was admitted due to heavy epistaxis, she was also diagnosed being allergic to aspirin.

Principal procedure: Due to excessive nasal bleeding hematocrit level of the patient decreased, she needs an immediate blood transfusion. 2 unit blood was transfused to increase the hematocrit level as well as hemoglobin of the patient.

Other procedures: The patient was taken to the treatment room, her cardiac movement, and oxygen level were monitored for whole night. As soon as the hematocrit level of the patient was maintained the bleeding time was delayed.

Conditions to clarify with the physician: The patient should clarify her earlier disease and surgical history to the physician. Along with these, she must also clarify that she is allergic and she was prescribed to avoid aspirin for her pain. In place of aspirin she must take Disalcid 750 mg.