The document discusses a 70-year-old male patient with recurrent bladder cancer and a history of significant medical issues, including coronary artery disease and past cancer treatments. The planned treatment is a radical cystectomy due to concerns about cancer recurrence affecting a diverticulum. The document also details the patient's medical history, allergies, and the potential complications associated with the surgery.

1. Identify the principal diagnosis and secondary diagnosis and place them in the correct
order. The ICD-10 2023 code options follow the Case study.
HISTORY OF PRESENT ILLNESS: This is a 70-year-old male I saw about a year ago. The
patient had cancer of the bladder with muscle invasion. Chemotherapy performed by Dr. Med. I
checked him one year ago and he was o.k. but I checked him a month ago and found that he had
a recurrent cancer. The only problem that bothers me is the cancer coming back right in through
the diverticulum on the right side. I am kind of worried about that might split out and that is
going to be a disaster. We decided to perform a radical cystectomy.
PAST MEDICAL HISTORY: The patient had a double bypass about ten years ago and also had
a stent placement in the heart about a month ago.
ALLERGIES: The patient has allergies to seafood and iodine.
SOCIAL HISTORY: The patient quit smoking about ten years ago and smoked almost half pack
a day.
REVIEW OF SYSTEMS: The review of systems is significant for colon cancer in the father.
PHYSICAL EXAMINATION: Generally, is alert. HEENT is within normal limits. The neck
was supple. The lungs were clear to auscultation and percussion. The heart was normal sinus
rhythm, no murmur. The abdomen was soft, no palpable mass or organomegaly. Extremities
were symmetrical, good pulses. External genitalia is normal. The prostate was very small - less
than 20 grams size and soft.
IMPRESSION: Cancer of the bladder recurrent and muscular invasion.
PLAN: Radical cystectomy with ileal conduit. He knows all the complications including
bleeding and also adjacent organ damage and possible blood clot. He decided to have the
operation done.
Z87.891 = History of tobacco use
K66.0 = Peritoneal adhesions
I73.9 = Peripheral vascular disease
C67.8 = Malignant neoplasm of the bladder
Z95.1 = Status post CABG
Z98.61. Status post PTCA
I25.10 = Coronary artery disease