Using the ICD-10 book, assign the proper diagnosis code to the following: Case Study 3
Skilled Nursing Facility Progress Note
VITAL SIGNS: BP: 120/80, Weight: 165 pounds, Temperature 100.1
This 84-year old man was seen today at the request of the charge nurse. The patient is experiencing urinary retention. No other complaints were noted by patient.
EXAM:
HEENT: Normal
CHEST: Lungs are clear
HEART: Normal sinus rhythm. No murmurs noted.
ABDOMEN: Soft, nontender. No masses noted.
RECTAL: Smooth enlarged prostate, no other findings noted.
Beacause of the enlarged prostate I ordered a PSA to rule out prostate cancer because the patient has not had a previous PSA completed. The following tests were also ordered: urinalysis and urine culture.
Patient will be seen again when results are received.
A) R33.9
B) N34.1
C) L32.2
D) N35.8