Right Knee Started Explained for Students (Easy Guide)

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Original Question

CC: “My right knee started hurting a week ago” History of Present Condition Chris is a new patient of this clinic who has had knee pain a few times before over the past 8 or 9 months, but it continues to get worse. Most recent onset of pain was about 1 week ago. It gets worse through the day and improves with rest. The pain is in the right knee all the way across the front, right where the knee bends. The pain is a dull, aching pain that is worse with weight bearing. On a 0-10 pain scale, at its worst it is a 6 or 7 at the end of the day after standing off and on. Most of the time the pain is a 1 or a 2 when sitting, just enough that he notices it, but not enough to keep him from doing normal activities. The pain does not radiate anywhere, but it is progressively getting worse. He has had similar pain for 8-9 months, at first it was just achy and lasted a couple of days, but it’s getting more painful and lasting longer. In the past, a couple of ibuprofen (Advil) has taken care of the soreness, but with this last episode the pain is not resolved with Advil. The knee currently feels a little swollen to the patient. Past Medical History and Current Status Childhood Illnesses: Unremarkable. He had chicken pox as a child. Adult Illnesses: High blood pressure for the past 2 years. Medications: Lisinopril 20 mg daily. Ibuprofen 200mg 2 PO every 6 hours as needed. Allergies: None Accidents & Injuries: He reports a few sports sprains/strains in high school, but describes it as, “nothing serious” Tobacco: none Alcohol, drugs & related substances: Alcohol 2-3 beers on Saturdays, No drugs. Diet: He tries to eat a balanced diet but finds it hard when cooking for one. Vaccinations: He is current with his flu shot. Family Medical History His mother and father are both healthy, he has two brothers who are healthy. Two children, who are healthy and do not live with him. No family history of cancer, diabetes, neuro problems, or back problems. Bio-Psycho-Social History Patient lives alone, he divorced about 2 years ago. He has two children who live with his ex-wife, one child has asthma. Occupation: He is employed as an information technology tech at the local hospital in the neighboring small town of Winslow. Socioeconomic Status: Works full time, has full benefits through work. Marital/Partner status: Divorced 2 years ago Living Environment: He lives in a 2 bedroom, 1 bathroom, apartment on the 2nd floor, there is no elevator in his building and he takes the stairs. Safety Measures: Uses seatbelts. Support Systems: Good relationships with family and friends. Important Life Experiences: He graduated from Pittsburg State University with a degree in information technology. Religious Affiliation: Catholic, goes to church regularly, is a part of the community there. Vitals Data Blood Pressure: 142/90 mmHg Heart Rate: 84 beats per minute Respiratory Rate: 18 breaths per minute Temperature: 98.7 F PATIENT NAME: PATIENT TYPE (highlight the appropriate patient type for this case) : IP OP ED PHYSICIAN Practice If Inpatient, what is the patient’s Principal Diagnosis in words, followed by the ICD-10 code? If inpatient, what is/are the patient’s secondary diagnosis(es) (if any) in words, followed by the corresponding ICD code(s). You are responsible for knowing and understanding the definition of a secondary diagnosis that needs to be coded as well as sequencing guidelines. What is/are the corresponding ICD- code(s) for the diagnosis(es) If inpatient, what is the patient’s principal procedure in words, followed by the ICD code? If inpatient, what is/are the patient’s secondary procedure(s) (if any) in words, followed by the corresponding ICD code(s)? You are responsible for knowing and understanding the definition of a secondary procedures that need to be coded as well as sequencing guidelines. If Outpatient/ED/Physician practice what is the patient’s Primary Diagnosis in words, followed by the ICD code? Are there any secondary diagnosis(es) (if any) in words that should be coded? You are responsible for knowing and understanding the definition of a secondary diagnosis that needs to be coded as well as sequencing guidelines. What is/are the corresponding ICD code(s) for the diagnosis(es). Are there any procedures that need to be coded; if so, code them in the proper order, using the proper coding system. TYPE, IN PROPER ORDER, THE DIAGNOSIS AND PROCEDURE CODE(s) for CASE 2 are:

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