ICD 10 Case presentation on 4/3/2021

1. Overview of MCCD
CASE PRESENTATION
By: Keshavarao.T
MBA(Hosp Mgt)BA,DMRT,MRO
Medical Records Officer (Health & FW Dept)
CIMS Teaching Hospital,
Chamarajanagar-
+91 9880569550
keshavarao.ssit@gmail.com

2. ------------------------------Hospital
SUMMARY SHEET
DATE OF ADMISSION AND TIME:
AGE: 51
SEX: Male
Occupation: Coolie
ICD CODE
PROVISIONAL
DIAGNOSIS
C/O Fever, Cough with Breathlessness
FINAL DIAGNOSIS Rheumatic Heart Disease with Mitral Stenosis
Mitral Regurgitation
with congestive cardiac failure.
OPERATION
PROCEDURES
-
CAUSE OF DEATH Cardio respiratory Arrest
secondary to CCF with history
of RHD.

3. C/C: Fever , Cough, with Breathlessness since 8 days, Pedal edema since 8 days.
History of present illness: Patient was apparently alright 8 days back the he
developed Fever, Cough with breathlessness which was sudden in onset and
progressive in nature
It is present on doing routine work as well as at rest. It increases on lying down
position. There are also complaints of swelling of both lower limb since 8 days,
which is insidious in onset an progressive in nature. It is present up to knee
from ankle
H/O Palpitation present, regular, increases on decreases on exertion and
decreases on rest, No H/O fever, Cough, and Chest pain.
Past History: No h/o similar complaints in the past in the past. No h/o DM,
HTN,TB
No h/o any previous hospitalization
Personal History: Diet Non Vegetarian, Appetite-Good, Sleep, Normal, Bowel
and Bladder-Regular, Others-Nil.
Family History: Nothing significant.
General Physical Examination: Here is a middle aged female patient who is

4. moderately build and nourished and conscious, co-operative and well oriented to
time, place, and person.
PR-80 beats/min, regular, high volume. BP-100/70 mmHg, RR-22 Breaths/min,
Temp-A febrile, Pallor-Absent, Icterus-Present, Cyanosis-Absent, Clubbing-Absent,
Lymphadenopathy-Absent, Edema-B/L pedal edema,++pitting type.
Systemic Examination:
CVS-S1 &S2 heard Normal, Pan systolic murmur and mid diastolic murmur present
in mitral area no additional sounds.
RS-B/L equal air entry present, B/L Basal crept present.
Abdomen- uniformly distended, fluid thrill present.
CNS-NAD
Diagnosis: Rheumatic Heart Disease with Mitral Stenosis with Mitral Regurgitation
with congestive cardiac failure.
Investigations:
ECG , Sputum, HB-12mg%, TC-5500 cells/mm. ESR:10 mm at the end of 1 hour,
Urine-Albumine-nil, Sugar-nil, Microscopy-NAD, USG Abdomen-Cystitis,

5. Fatty Liver, Moderate Ascitis.
Patient Stayed in hospital 9 days and during that time he had given treatment as
follows:
Inj-Lasix 1 ample IV, Inj Vit-K 1 amp in OD for 3 days, Inj BC 2cc in ATD,Inj Taxim 1
mg IV, Inj Deriphylline 1 amp IV, Inj Rantac 1 amp IV, Inj Perinorm 1 amp IV,
Tab.FS, Tab BC, Tab Liv 52. Paracetomol 500mg
Cause of Death-Cardio Respiratory arrest secondary to CCF with history of RHD.
Patient Expired On :8/3/2021 at 3pm

6. Cause of Death ICD
Code
1
Immediate Cause.
State the disease, Injury or complications
Which caused death not the mode of dying
Such Heart failure, Asthma etc,.
(a) Immediate Cause:
CARDIO RESPIRATORY ARREST
Due to (or as a consequences of)
Antecedent Cause
Morbid conditions, if any giving rise to above
cause stating underlying condition list.
(b) CONGESTIVE CARDIAC FAILURE
Due to (or as a consequences of)
(c) RHEUMATIC HEART DISEASE
II
Other significant condition contributing to the
death but not related to the disease or
conditions causing it,
------

7. QUESTIONNAIRE
ASSING THE ICD-10 CODES FOR FOLLOWING THE FINAL DIAGNOSIS?
1) Rheumatic Heart Disease with______________________
2) Mitral Regurgitation with Mitral Stenosis _____________
3) with congestive cardiac failure.______________________
and
WHAT IS THE ICD-10 CODES OF FOLLOWING THE CAUSE OF DEATH?
1) CARDIORESPIRATORY ARREST _____________________
2) CONGESTIVE CARDIAC FAILURE____________________
3) RHEUMATIC HEART DISEASE_______________________

8. ANS:
FD-1) RHD-I09.9 2)MR/MS-I05.2 Insufficiency-Mitral-Stenosis 3)CCF-I50.0
COD-1)CRA- I46.9 2)CCF-I50.9 3)I09.9 3)RHD-I09.9
THANK YOU EVERYONE