Get Answer: History Present Illness Question Guide

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What This Question Is About

This question relates to history present illness and requires a structured academic response.

How to Approach This Question

Break the problem into smaller parts and analyze each logically.

Key Explanation

This topic involves history present illness. A strong answer should include explanation, application, and examples.

Original Question

History of present illness: The patient is a 72-year-old male who was involved in an interpersonal alternation at approximately 1:30 am. He presented to the emergency department with complaints of pain and swelling to the right side of the face. The patient had been struck multiple times with the butt end of a handgun. He denied loss of consciousness. The attack was witnessed, and the witnesses also claim there was no loss of consciousness. He presented with pain and swelling on the right side of his face in the temporal region and in the right eye region. He had a small abrasion on the top of his head and on the right forehead. No lacerations were noted. He had no diplopia. The past medical and surgical histories were noncontributory. The patient was taking no medications and had no allergies. Laboratory Data: Admission x-rays and CT scan revealed a nondisplaced right zygoma fracture and an orbital floor fracture with slight limitation of his upward gaze on physical examination. Hospital course: He was taken to the operating room from open reduction of the facial fracture and placement of a Silastic implant to right orbital floor fracture, which was accomplished without difficulty or complication. The patient tolerated the procedure well. Postoperative courses was uncomplicated. He received intravenous antibiotics throughout his hospital stay. Currently, he is tolerating a general diet without problems. He was up and above, ambulating without difficulty. He will be seen here at the hospital on Saturday for suture removal. Discharge medications: Keflex, 500 mg to be taken q.i.d. for 1 week. Final Diagnoses: Right orbital fracture, right zygoma fracture, and abrasions of the head. Operations: Exploration and placement of a Silastic implant to the right orbital floor fracture. Codes Assigned: Principal DX: S02.3XX Additional Diagnoses Codes: S02.402A Procedure codes: 0NSN3ZZ, 0NSP04Z Do you agree with the ICD-10-CM codes assigned? If not, what ICD-10-CM codes should by assigned? Do you agree with the ICD-10-PCS codes assigned? If no, what ICD-10-PCS codes should be assigned? Do you have any concerns/issues for a physician query?

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