Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list.
Patient: Lorraine Parnete
Physician: Jason Nuouri, MD
July 16, 2018
History
A well-established, 67-year-old female patient (since 1991) has controlled hypertension with no complications. She is a smoker [cigarettes, about one pack a day] and takes clonidine and HCTZ for her hypertension, and estrogen to address menopausal symptoms. Overall, she is well and fully active.
Examination
Patient presents with fatigue, about 1 month duration, associated with the withdrawal from estrogen because of published data suggesting an increased risk of breast cancer and other complications. Exam includes complete review of systems. CXR [chest x-ray] and PPD (tuberculin skin test) are negative except for the following:
cough with minimal sputum
a low grade fever to about 100°F
5 pound weight loss
Plan
Order for CBC, glucose tolerance test, TSH.
Patient to return to discuss lab results.
Be sure to list the codes, one code per box, in the correct order, from top to bottom. Capitalization, punctuation, and spacing can impact whether or not your answer is correct. Follow coding best practices.
What is/are the correct diagnosis code(s)?
