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Emergency Department Services:
History: The patient is an 86-year-old female brought into the ER with a pleural effusion, UTI,
and dehydration. She had been taking medication. She lives at a nursing home and has been
doing well. Today she was found to be weak, with a poor appetite. Then she was sent to the ER
for evaluation and found to have pleural effusion, dehydration, UTI, and thrombocytopenia with
petechial hemorrhage. She was found to have a platelet count of 77,000.
Past History: She has a history of cholecystectomy.
Social History: No smoking, drinking or allergies.
Impression:
1. Urinary Tract Infection
2. Dehydration
3. Pleural effusion from chronic diastolic CHF
4. Primary thrombocytopenia with petechial hemorrhage
5. Type I diabetes
Plan: The patient will be stabilized and started on IV fluids. An IV antibiotic for UTI will also
be started.
What are the 5 ICD-10 diagnoses for this patient?

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Emergency Department Services History The patient is an 86-year.pdf

  • 1. Emergency Department Services: History: The patient is an 86-year-old female brought into the ER with a pleural effusion, UTI, and dehydration. She had been taking medication. She lives at a nursing home and has been doing well. Today she was found to be weak, with a poor appetite. Then she was sent to the ER for evaluation and found to have pleural effusion, dehydration, UTI, and thrombocytopenia with petechial hemorrhage. She was found to have a platelet count of 77,000. Past History: She has a history of cholecystectomy. Social History: No smoking, drinking or allergies. Impression: 1. Urinary Tract Infection 2. Dehydration 3. Pleural effusion from chronic diastolic CHF 4. Primary thrombocytopenia with petechial hemorrhage 5. Type I diabetes Plan: The patient will be stabilized and started on IV fluids. An IV antibiotic for UTI will also be started. What are the 5 ICD-10 diagnoses for this patient?