Wiki Help with this pre-op clearance


Marrero, LA
Best answers
Help this is coded wrong?

Back Pain *

Associated Diagnoses: Back pain; Degenerative disc disease; Preoperative Clearance

Visit Information
Visit type: Increase in symptoms.
Accompanied by: Spouse.

Chief Complaint
back pain
preop clearance for cataract surgery

History of Present Illness
Exacerbating factors consist of movement. Relieving factors consist of ibuprofen didn't help.

Review of Systems
Constitutional: Negative except as documented in history of present illness.
Eye: Negative.
Ear/Nose/Mouth/Throat: Negative.
Respiratory: Negative.
Cardiovascular: Negative.
Gastrointestinal: Negative.
Genitourinary: Negative.
Hematology/Lymphatics: Negative.
Endocrine: Negative.
Immunologic: Negative.
Musculoskeletal: Back pain.
Integumentary: Negative.
Neurologic: Negative.
Psychiatric: Negative.
All other systems are negative

Health Status
Allergies: .

No active allergies have been recorded.

Problem list: .
All Problems
arthropathy neck/hands
chronic neck pain
Hyperlipidemia, mixed 272
lumbar radiculopathy/DJD
Menopause 627.2
right ear pain
Unspecified Essential Hypertension / ICD-9-CM 401.9
Pure Hypercholesterolemia / ICD-9-CM 272.0
Routine General Medical Examination at a Health Care Facility / ICD-9-CM V70.0
Unspecified Chest Pain / ICD-9-CM 786.50
Insomnia, Unspecified / ICD-9-CM 780.52
Allergic Rhinitis, Cause Unspecified / ICD-9-CM 477.9
Pain in Joint, Site Unspecified / ICD-9-CM 719.40
Arthropathy Unspecified, Involving Other Unspecified Sites / ICD-9-CM 716.98
Osteoarthrosis, Unspecified Whether Generalized or Localized, Involving Hand / ICD-9-CM 715.94
Need for Prophylactic Vaccination and Inoculation Against Other Viral Diseases / ICD-9-CM V04.8
Sebaceous Cyst / ICD-9-CM 706.2
Tietze's Disease / ICD-9-CM 733.6
Benign Essential Hypertension / ICD-9-CM 401.1
Esophageal Reflux / ICD-9-CM 530.81
Unspecified Viral Infection in Conditions Classified Elsewhere and of Unspecified Site / ICD-9-CM 079.99
Spasm of Muscle / ICD-9-CM 728.85
Tachycardia, Unspecified / ICD-9-CM 785.0
Symptomatic Menopausal or Female Climacteric States / ICD-9-CM 627.2
Other Malaise and Fatigue / ICD-9-CM 780.79
Other Specified Anemias / ICD-9-CM 285.8
Anemia, Unspecified / ICD-9-CM 285.9
DYSURIA / ICD-9-CM 788.1
Otalgia, Unspecified / ICD-9-CM 388.70
Acute Swimmers' Ear / ICD-9-CM 380.12
Brachial Neuritis or Radiculitis Nos / ICD-9-CM 723.4
Pure Hyperglyceridemia / ICD-9-CM 272.1
Reflux Esophagitis / ICD-9-CM 530.11
Thoracic or Lumbosacral Neuritis or Radiculitis, Unspecified / ICD-9-CM 724.4
Other Disorders of Bone and Cartilage / ICD-9-CM 733.99
Need for Prophylactic Vaccination Against Streptococcus Pneumoniae [pneumococcus] / ICD-9-CM V03.82
Need for Prophylactic Vaccination and Inoculation Against Streptococcus Pneumoniae [pneumococcus] and Influenza / ICD-9-CM V06.6
Other and Unspecified Adverse Effect of Drug, Medicinal and Biological Substance / ICD-9-CM 995.2
Need for Prophylactic Vaccination and Inoculation Against Influenza / ICD-9-CM V04.81
Urinary Tract Infection, Site Not Specified / ICD-9-CM 599.0
Pain in Limb / ICD-9-CM 729.5
Unspecified Menopausal and Postmenopausal Disorder / ICD-9-CM 627.9
EDEMA / ICD-9-CM 782.3
Malignant Essential Hypertension / ICD-9-CM 401.0
Long-Term (Current) Use of Other Medications / ICD-9-CM V58.69
Angioneurotic Edema, Not Elsewhere Classified / ICD-9-CM 995.1
Bronchitis, Not Specified as Acute or Chronic / ICD-9-CM 490
Predominant Disturbance of Emotions / ICD-9-CM 308.0
Memory Loss / ICD-9-CM 780.93
Other Abnormal Blood Chemistry / ICD-9-CM 790.6
Unspecified Gastritis and Gastroduodenitis, without Mention of Hemorrhage / ICD-9-CM 535.50
Shortness of Breath / ICD-9-CM 786.05
Cellulitis and Abscess of Upper Arm and Forearm / ICD-9-CM 682.3
Need for Prophylactic Vaccination and Inoculation Against Other Specified Disease / ICD-9-CM V05.8
Acute Sinusitis, Unspecified / ICD-9-CM 461.9
WHEEZING / ICD-9-CM 786.07
Contact Dermatitis and Other Eczema / ICD-9-CM 692
Unspecified Deficiency Anemia / ICD-9-CM 281.9
Insect Bite, Nonvenomous, of Foot and Toe(s), without Mention of Infection / ICD-9-CM 917.4
Insect Bite, Nonvenomous, of Hand(s) Except Finger(s) Alone, without Mention of Infection / ICD-9-CM 914.4
Obesity / ICD-9-CM 278.00 / Probable

Past Medical History: .
No active or resolved past medical history items have been selected or recorded.
Family History: .
No family history items have been selected or recorded.
Procedure history: .
No active procedure history items have been selected or recorded.
Social History
. No active social history items have been recorded.

Physical Examination
Vital Signs
Temperature Oral 98.2 DegF
Peripheral Pulse Rate 75 bpm
Respiratory Rate 18 br/min
Systolic Blood Pressure 119 mmHg
Diastolic Blood Pressure 71 mmHg
BP Site Right arm
, Measurements from flowsheet : Measurements
:confused: Height 62.00 in
Weight 160.00 lb
BSA 1.78
Body Mass Index 29.26 kg/m2
Ht/Wt Measurement Refused by Patient? No

General: Alert and oriented, No acute distress.
Eye: Pupils are equal, round and reactive to light, Extraocular movements are intact.
HENT: Tympanic membranes are clear.
Mouth: Within normal limits.
Throat: Within normal limits.
Neck: Supple, Non-tender.
Respiratory: Lungs are clear to auscultation.
Respirations: Are within normal limits.
Cardiovascular: Normal rate, No murmur.
Gastrointestinal: Soft, Non-tender, Non-distended.
Genitourinary: No costovertebral angle tenderness.
Lymphatics: No lymphadenopathy neck, axilla, groin.
Musculoskeletal: Normal range of motion, Normal strength.
Spine/torso exam: Lumbar ( Bilateral ).
Integumentary: Warm, Dry, Pink.
Feet: Normal by visual exam.
Neurologic: Alert, Oriented, Normal coordination.
Coordination: Within normal limits.
Psychiatric: Cooperative, Appropriate mood & affect, Normal judgment, Non-suicidal.

Impression and Plan
Back pain (ICD9 724.5).
Degenerative disc disease (ICD9 722.6).
Preoperative Clearance (ICD9 V72.84).

Doctor Coded