Codificarea practic

Cazuri clinice

Exerciii

Cazuri aduse de cursani www.icg2000.ro

doriny27@gmail.com
mihaelai@icg2000.ro

tionescu@ccss.ro
pertache@ccss.ro

Cazul 1

MI:B,83, 58K162cm,

Dureri CV, bazin

Traumatism cadere pom - 3 zile

Dg.Internare:
Tr.bazin disjuncie pubiana,
luxatie sacroiliaca. Contuzie CV
Obiectiv: reducere disjunctie
pubiene

APP

Adenom prostata operat 2001,

Menisc 1987, Boala hemoroidala
operata, HTA
trat metoprolol, leridip,
nitropector, betaserc,

Evoluie:

ameliorat

Reducerea disjunctiei prin

suspendare in hamac

Proceduri dg i terapeutice:

Proceduri chirurgicale:

Istoric:

Rx CV lombara, bazin
Trat AINS, decontracturant

Dg.Final:

Disjunctie pubiana
Luxatie sacroiliaca
Entorsa CV lombara

Cazul 1 - codificare

Dg.P: Disjunctie pubiana S33.4

Dg.S

Proceduri:

Luxatie sacroiliaca S33.2

Entorsa CV lombara S33.5

Reducerea disjunctiei prin suspendare in hamac 47483-00

DRG:
vr:

Cazul 1_1
Dg.Principal
Disjuncie pubian

Proceduri
S33.3

Reducerea disjunciei prin

suspendare n hamac

47483-00

Rx CV, Rx bazin
Kinetoterapie

Dg.secundare
Luxaie sacroiliac

S33.2

Entors CV

S33.51

Leziune funcional CV L

S34.70

HTA

I10

Cdere din pom

Alte acc.domestice

W14
U73.1
Y92.09

MDC 08; DRG I68B

PCCL 0 ; vr 0,96

95550-03

Cazul 2

MI:B,58, 58K,160cm

Durere coapsa dr,
tumefactie, impotenta
Istoric:

Tr.cadere propria inaltime
APP

HTA, AVC
Dg.Internare:

Fractura coapsa
Evoluie:

Operatvindecat ch

Ziua 2 AIT  remite

Proceduri chirurgicale:

Proceduri dg i
terapeutice:

Reducere sangerinda si
fixare prin osteosintez
centromedular tij
blocat retrograd

Radiografii
Evaluare lab.

Dg.Final:

Fr.intens cominutiv 1/3

distal femur stng.
HTAE II, CICND, AVC

Cazul 2 - codificare

Dg.P

Dg.S

Fr.intens cominutiv 1/3 distal femur stng S72.3

AVC I61.9
HTA
CICN

Proceduri:

Reducere sangerinda si fixare prin osteosintez centromedular tij blocat

retrograd 4752847528-01

RX

DRG:
vr:

Cazul 2_1
Dg.Principal
Frc.cominutiv 1/3 distal
femur stg

Proceduri
S72.42

Dg.secundare

Reducere sngernd, fixare 47528-01

prin osteosintez centromedular, tij blocat
Rahianestezie (ASA??)

92508-10

Kinetoterapie

95550-03
95550-08

AVC ischemic NES

G45.9

Educaie folosire crje

HTA

I10

Rx.osoase

?CICND

I25.6

Cadere proprie nlime

LOC??NES
Activitate?? NES

W19
U73.9

MDC 08; DRG I08B

PCCL 0 ; vr 3.06

Cazul 3

MI:SM, F, 39, 56K,162cm

apendicetomie
Sarcin 5spt, ameninare
avort

Evoluie:

Avort 1 zi spontan
Polip endocervical

Proceduri chirurgicale:

Dg.Internare:

Istoric:

Metroragie dup 45 zile

Proceduri dg i
terapeutice:

Chiuretaj uterin

Ecografie pelvin

Dg.Final:

Avort 5 spt incomplet

efectuat

Cazul 3 - codificarae

Dg.P

Dg.S

Polip endocervical N841

Proceduri:

Avort 5 spt incomplet O031

Chiuretaj uterin 35643-00

Extirpare polip 35608-02

DRG:
vr:

Cazul 3_1
Dg.Principal
Avort incomplet fr
complicaii

Proceduri
O03.1

Dg.secundare
Durata sarcinii

O09.1

Polip endocervical

N84.1

Chiuretaj uterin

35643-00

Extirpare polip

35608-02

Anestezie local

92513-10

MDC 14; DRG O05Z

PCCL 2 ; vr 0,45

Cazul 4

MI: B, 73, 85K,175cm

Operat recent tumor

RectoSigm. Anus Iliac stg

Dg.Internare:

Eventraie subombilicala
mutisaculara cu defect
parietal 16/10
Sdr.subocluziv n ansele din
ev.

Evoluie:

Operat, vindecat

Proceduri chirurgicale:

Istoric:

Eventraie gigant, defect

perete

Proceduri dg i terapeutice:

Cura eventraiei cu plasa

AB, pev, vitamine
Rx abdominal

Dg.Final:

Eventraie gigant
multisacular subombilical

Cazul 4 - codificare

Dg.P

Eventraie gigant multisacular subombilical K46.0

Dg.S

Sdr.subocluziv K56.6

Proceduri:

Cura eventraie cu plasa de substitutie - 30405-01

Rx

DRG:
vr:

Cazul 4_1
Dg.Principal
Eventraie median cu
ocluzie fr gangren

Proceduri
K43.0

Cura eventraiei

30405-01

Anestezie general

92514-20

Dg.secundare
Sdr.subocluziv

K56.6

Anus iliac

Z93.3

Antecedent tumoral

Z85.0

MDC 06; DRG G08A

PCCL 3 ; vr 1,59

Cazul 5

MI:VD, M, 55, 53K,165 cm

Istoric:

Fum
Fumtor, consumator alcool
TB pulm sec LSB, disemin
diseminri bilat.
Recidiva si BK neg. Reluare trat
Subponderal, tahicardic, cardiomegalie

Proceduri chirurgicale:
Proceduri dg i terapeutice:

TB 2003,2006 trat incorect

Dg.Internare:

APP

Simpt TB, recidiv

recidiv TB

Dg.Final:

Evoluie:

Reluare trat TB
Vasodilatorii, antianti-HTA, antialgice,
antiemetice, AINS
ameliorat

Ex sputa BK pozitiv,
RxCP leziuni active confluente,
CT pulm neag
neag TM
RxCP control

TBC pulm sec. Cazeos cavitar,

LSB micronodular
micronodular remaniat
remaniat
subjacent bilateral
bilateral,
recidiv
recidiv....BK negativ la
externare......
CPC par
parial compensat, I.Resp.Cr.,
Crize anginoase, HTA pusee,
Efecte adverse ale medica
medicaiei
antiTB. Etilism cronic.

Cazul 5 - codificare

Dg.P

A15.1

Dg.S

TB

CPC
I27.9
I.Rp.Cr
J96.1
Crize anginoase I20.9
HTA I15.9
RAdv.medic Y41.1
Etilism cronic F102

Proceduri:

Trat oral
9602796027-00
Inj
9218692186-00
TC,
Monitorizare TA
nso
nsoire pac investiga
investigaii 9617196171-00

DRG:
vr:

Cazul 5_1
Dg.Principal
TB

Proceduri
A15.1

TC
nsoire Pac Investigaii
Kinetoterapie

Dg.secundare
CPC

I27.9

IRpCr

J96.1

Angina stabil
HTA

I20.9
I10

Hep.toxic medic

K71.1

R adv medic, spital

Y41.1
Y92.22

MDC 04; DRG E62A

Etilism cronic

F102

PCCL 4 ; vr 2,65

Educaie ...

96171-00

Cazul 6

MI: IA, 69M, 70K,170cm

Istoric:

n urm 9 ani TCC, comotie

medie vertij poziional, cefalee

Dg.Internare:

Cefalee, vertij, insomnie

Depresie cu idei autoliza
Deficit mnezic i prosexic
Durere hipoc.dr, grea

Tulb.afectiv depresiva de
intensitate medie pe fond
somatic

Evoluie:

Trat. Piracetam, silimarina,

meprobamat
Pev G10%,vit, meprobamat,
haloperidol sol. po, diazepam inj,
alprazolam
DS 9zile

Proceduri chirurgicale:
Proceduri dg i terapeutice:

Rx.craniu
Paraclinice

Dg.Final:

Tulb afectiv depresiv de

intensitate medie pe fond
somatic

Cazul 6 - codificare

Dg.P

Dg.S

Hep.cr.activ K73
TCC n antecedente cu comoie cerebral i vertij menieriform S433

Proceduri:

Episod depresiv mediu F321

Evaluare mental i comportamental 96175Psihoterapie interpersonal 96177

Cateterizarea unei vene 90220
Consiliere legat de abuzul fizic-violenta-atac 96084
Injectarea unui tranchilizant 92190
Consiliere sau educatie preventiv 96066

DRG:
vr:

Cazul 6_1
Dg.Principal
Episod depresiv mediu

Proceduri
F32.10

Evaluare mental...

96175-00

Psihoterapie

96177-00

Dg.secundare
Hep.Cr activ

K73.2

Consiliere abuz

96084-00

Cefalee post-tr.

G44.3

Injectare tranchilizant

92190-00

MDC 19; DRG U63A

PCCL 2 ; vr 3,55

Cazul 7

MI:GO, 64F,

Istoric:

Pac.cronic cu agravare acuze

secundar unor psihotraume
familiale

APP:

Astenie, fatigabilitate, depresie

sever, labilitate emoional, idie
cu coninut micromanic, toleran
sczut la frustri

DZ II, Hep viral, ICVB,

Spondiloz CDL,
Colecistectomie

Dg.Internare: Tulb depresiv

sever pe fond psihoorganic
Evoluie:

trat nitrazepam, dizepam,

serlift, tranxene, memotal,
alindor, vit B
14 zile, ameliorat

Proceduri chirurgicale:
Proceduri dg i terapeutice:

Expl paraclinice curente

Dg.Final: Tulb afectiv pe

fond psihoorganic cr
deteriorativ, episod sever

DZ insulinoindependent
Spondiloz CDL
Tulb circulatorii
vertebrobazilar

Cazul 7 codificare

Dg.P: Tulb afectiv pe fond psihoorganic cr deteriorativ, episod

sever: F322 i F063
Dg.S

Proceduri:

DZ insulinoindependent
E11
Spondiloz CDL
M47.1
Tulb circulatorii vertebrobazilar I67.8

Regim diabet

DRG:
vr:

95550-00

Cazul 7_1
Dg.Principal
Tulb afectiv fond
psihoorganic cr
deteriorativ

Proceduri
F32.20

Dg.secundare
Episod sever

F06.3

DZ insulinodependent
(!!!! Fr complicaii??)

E11.9

Spondiloz CDL

M47.20

Tulb.circ VB

I67.8

MDC 19; DRG U63A

PCCL 2 ; vr 3,55

Cazul 8

MI: PD, 72M,

HTA, BCI 1991, Astm br 1992,

B.artrozic 2000

Dg.Internare:

Demen mixt

Evoluie:

Proceduri chirurgicale:
Proceduri dg i
terapeutice:

CT

deteriorare progresiv 2 ani

APP:

Istoric:

Ecmnezie, amnezie fixare i

evocare, disfazie, tulburarea
funciei de execuie, agnozie,
tulb comportament

Trat zeplan, aricept, enap,

aspenter, nicergolin
9zile, staionar

Dg.Final: Demen
Alzheimer cu debut
tardiv i tulburri de
comportament. HTAE II,
BCI, F.atrial, ICC III
NYHA, Dislipidemie

Cazul 8 - codificare

Dg.P Demen Alzheimer cu debut tardiv i tulburri de

comportament F00.1

Dg.S

Proceduri:

HTAE II
BCI
Fibrilaie atrial
ICC II NYHA
Displipidemie
CT

DRG:
vr:

I15.9
I25.9
I48
I50.0
E78.9

Cazul 8_1
Dg.Principal
Demen Alzheimer debut
tardiv

Proceduri
G30.0+

CT

Dg.secundare
Dementa

F00.1*

HTAE

I10

BCI

I25.9

Fibrilaie atrial

I48

ICC II NYHA

I50.0

MDC 01; DRG B63Z

Dislipidemie NEC

E78.9

PCCL 3 ; vr 2,85

MI:SB, 9L, M, 8400G,

Febr, vrsturi, scaune

apoase, placarde
eritematoase pruriginoase
generalizate, dureri
abdominale difuze

Istoric: 24 ore
eruptiigeneralizarefebr
int
APP Dg.Internare:

Cazul 9

Sdr.diareic acut febril

Evoluie:

Ampi, biseptol, HHC,

lorantadin, Ca.carbonic,
algocalmin
26zile vindecat

Proceduri chirurgicale:

Proceduri dg i
terapeutice:

Snge, coprocultur,
coproparazitologic

Dg.Final: Enterocolit
acut. Sdr.dispeptic.
Alergodermie. Anemie
feripriv

Cazul 9 - codificare

Dg.P

K30
T887
D509

Dispepsia
R.adv.medic nespecificat
Anemie deficit de fier NOS

Proceduri:

Gastroenterit neinfecioas

Dg.S

K529

13839-00
95550-11
96066-00
92204-00
58500-00
96027-00

DRG:
vr:

Recoltarea de snge n scop diagnostic

Alte intervenii nemedicale
Consiliere preventiv
Teste noninvazive NEC
Rx torace
Evaluarea automedicaiei i schema terapeutic

Cazul 9_1
Dg.Principal
Diaree ac.probabil inf

Proceduri
A09

Rx
Educaia mamei ?

Dg.secundare
Deshidratare

E86

Rash NEC

R21

Anemie deficit fier

D509

MDC 06; DRG G68A

PCCL 2 ; vr 1,19

Cazul 10

MI:FA, F3L, 6500g

Istoric:

Proceduri chirurgicale:

Proceduri dg i terapeutice:

GN 3200g, alimentaie mixt

Dg.Internare:

Febr, tuse, agitaie, refuzul

de a se alimenta

Pneumonie acut. I.Rp.Acut

Febril, cianoz, agitat,
dispeptic, RR60/min, raluri
subcrepitante bilateral,
meteorism abdominal

Evoluie:

Trat: AB, cortizon, miofilin,

antitermice, bicarbonat,
oxigen
Ev. Sdr dispeptic remis
Vindecat la externare
Durata spitalizrii 10zile

Analize snge
Rx.CP broniolit acut

Dg.Final:

Insuficien respiratorie
acut. Broniolit acut.
Gastroenterit acut.
Hipertrofie de timus.Anemie
carenial.

Cazul 10 - codificare

Dg.P:
Dg.S:

Proceduri:

DRG:
vr:

Cazul 10_1
Dg.Principal
Broniolit acut

Proceduri
J21.9

Dg.secundare
Gastroenterit acut

A09

Anemie carenial

D53.9

MDC 04 ; DRG E70A

PCCL 3 ; vr 1,65

Cazul 11

MI:AI, F5A, G15Kg, T 112cm

GN 3300g, alimentaie
diversificat, vaccinuri
curente
Amigdalit pultacee internat

Dg.Internare:

Istoric:

Febr, disfagie, dureri

abdominale de 2 zile

Sdr.dispeptic. IACRS

Evoluie:

Trat: penicilin +
gentamicin, ibugesic,
debridat, faringosept,
peritol, HHC
5 zile
vindecat

Proceduri chirurgicale:
Proceduri dg i
terapeutice:

Ex.ORL
Ecografie abdominal

Dg.Final:

ITU E.coli. Colic

abdominal. Rinoadenoidit
cronic. Amigdalit
cronic. Sindrom minor
poststreptococic.

Cazul 11 - codificare

Dg.P: ITU E.coli : N39.0 i B96.2

Dg.S:

Colic abdominal.
R10.8
Rinoadenoidit cronic.
J35.9
Amigdalit cronic.
J35.1
Sindrom minor poststreptococic.

Proceduri:

DRG:
vr:

R76.9

Cazul 11_1
Dg.Principal
ITU

Proceduri
N10

Ecografie
Rx.

Dg.secundare
E.Coli

B96.2

Rinoadenoidit cronic

J35.9

Amigdalit cronic
MDC 11 ; DRG L63C
PCCL 0 ; vr 0,68

Cazul 12

MI: NI, M11A, G21Kg, T

n timpul jocului cade peste un

grdule
rdule metalica, un st
stlp, apoi cade
jos.
Amigdalectomie 6A
St.gen.alterat
St.gen.alterat, palid, abdomen cu
mobililizare redus
redus la respira
respiraie,
marc
marc traumatic
traumatic 6cm, paraombilical
stg cu tumefac
tumefacia peretelui. Semne
clinice de frc.clavicul
frc.clavicul dr.

Dg.Internare:

Durere abdominal
abdominal, marc
marc
traumatic
traumatic abdominal
abdominal; tumefac
tumefacie i
durere clavicul
clavicul dreapt
dreapt

Traumatism abdominal. Abdomen

acut posttraumatic. Frc.clavicul
Frc.clavicul
dreapt
dreapt. oc posttraumatic.

Evoluie:

Trat: AB, antialgice, pev

Vindecat 7 zile

Proceduri chirurgicale:

Istoric:

Proceduri dg i terapeutice:

Anestezie general
general
Laparatomie exploratorie
Rezec
Rezecie segmentar
segmentar intestin
sub
subire cu anastomoz
anastomoz terminoterminoterminal
terminal
Cura eventra
eventraiei
Toalet
Toalet, drenaj
Investiga
Investigaii laborator
Ecografie abdominal
abdominal
Rx.clavicul
Rx.clavicul

Dg.Final:

Ruptur
Ruptur traumatic
traumatic intestin
sub

ire
sub
Eventra
Eventraie traumatic
traumatic flanc stg
abdominal
Peritonit
Peritonit generalizat
generalizat
Fractura claviculei dr
oc traumatic

Cazul 12 - codificare

Dg.P: Ruptur traumatic intestin subire S36.400

Dg.S:

Eventra
Eventraie traumatic
traumatic flanc stg abdominal
Peritonit
Peritonit generalizat
generalizat
Fractura claviculei dr
oc traumatic

Proceduri:

Rezec
Rezecie intestin sub
subire cu anastomoz
anastomoz
Anestezie general
general IOT
Laparatomie exploratorie
Cura eventra
eventraiei
Debridare i lavaj cavitate peritoneal
peritoneal
Imobilizare frc.clavicul
frc.clavicul

DRG:
vr:

3056630566-00
9251492514-20
3037330373-00
9032990329-00
3039630396-00
4746247462-00

S31.830 (cod plaga deschisa!!)

K65.0
S42.0
T79.4
W13

Cazul 12_1
Dg.Principal
Ruptur traumatic
intestin subire

Proceduri
S36.40

Rezecie intestin subire cu 30566-00

anastomoz
Anestezie general IOT

92514-20

K43.9

Cura eventraiei

30403-01

Peritonit generalizat

K65.0

Debridare i lavaj cavitate

peritoneal

30396-00

oc traumatic

T79.4

Imobilizare frc.clavicul

47462-00

Frc.clavicul (NOS!!)

S42.00

Cdere acelai nivel

alunecare/dezechilibru

W01.2

MDC 06 ; DRG G02A

coal n pauz

U69.1

PCCL 4 ; vr 7,04

Dg.secundare
Eventraie traumatic
flanc stg abdominal
(f
(fr obstruc
obstrucie sau gangren
gangren)

Cazul 13

MI:ME, 32F,

Dureri abdominale,
tulb.tranzit

Istoric:

Proceduri chirurgicale:

Proceduri dg i
terapeutice:

Inf.urinar, RVP,
incontinen urinar efort,
litiaz urinar

Dg.Final:

Dg.Internare: PNC acutizat.

Colopatie cr. Gastrit cr.
Inf.urinar
Evoluie:

Trat: cefaclor, urovaxom,

debridat, bilobil

Rectosigmoidoscopie

Pielonefrit cronic
acutizat (litiazic).
Colibaciloz urinar.
Ruptur Veche de
Perineu. Colon
iritabil. Gastrit
cronic.

Cazul 13 - codificare

Dg.P: Pielonefrit cronic acutizat (litiazic). N20.9

Dg.S:

Proceduri:

Colibaciloz urinar.
B96.2
Ruptur Veche de Perineu. O70.9
Colon iritabil.
K57.9
Gastrit cronic.
K29.3
EDS
Rectosigmoidoscopie
Ecografie abdominal, ECG, Ecocardiografie, RxCP, Rx.CV Cervical,
RxGD

DRG:
vr:

Cazul 13_1
Dg.Principal
ITU/PNA + Litiaz

Proceduri
N20.9

EDS

30473-00

Rectosigmoidoscopie

32084-00

Dg.secundare
E.Coli

B96.2

RVP (obst O70.9 )

N81.8

Colon iritabil

K58.9

Gastrit cronic

K29.3

MDC 11 ; DRG L64Z

PCCL 0 ; vr 0,52

Cazul 14

MI:

Istoric:

Dg.Internare:

Evoluie:

Proceduri
chirurgicale:

Proceduri dg i
terapeutice:

Dg.Final:

Cazul 14 - codificare

Dg.P:
Dg.S:

Proceduri:

DRG:
vr:

Cazul 14_1
Dg.Principal

Proceduri

Dg.secundare

MDC ; DRG
PCCL ; vr

Cazul 15

MI:

Istoric:

Dg.Internare:

Evoluie:

Proceduri
chirurgicale:

Proceduri dg i
terapeutice:

Dg.Final:

Cazul 15 - codificare

Dg.P:
Dg.S:

Proceduri:

DRG:
vr:

Cazul 15_1
Dg.Principal

Proceduri

Dg.secundare

MDC ; DRG
PCCL ; vr

Cazul 16

MI:

Istoric:

Dg.Internare:

Evoluie:

Proceduri
chirurgicale:

Proceduri dg i
terapeutice:

Dg.Final:

Cazul 16 - codificare

Dg.P:
Dg.S:

Proceduri:

DRG:
vr:

Cazul 16_1
Dg.Principal

Proceduri

Dg.secundare

MDC ; DRG
PCCL ; vr

Cazul 17

MI:

Istoric:

Dg.Internare:

Evoluie:

Proceduri
chirurgicale:

Proceduri dg i
terapeutice:

Dg.Final:

Cazul 17 - codificare

Dg.P:
Dg.S:

Proceduri:

DRG:
vr:

Cazul 17_1
Dg.Principal

Proceduri

Dg.secundare

MDC ; DRG
PCCL ; vr

Cazul 18

MI:

Istoric:

Dg.Internare:

Evoluie:

Proceduri
chirurgicale:

Proceduri dg i
terapeutice:

Dg.Final:

Cazul 18 - codificare

Dg.P:
Dg.S:

Proceduri:

DRG:
vr:

Cazul 18_1
Dg.Principal

Proceduri

Dg.secundare

MDC ; DRG
PCCL ; vr

Cazul 19

MI:

Istoric:

Dg.Internare:

Evoluie:

Proceduri
chirurgicale:

Proceduri dg i
terapeutice:

Dg.Final:

Cazul 19 - codificare

Dg.P:
Dg.S:

Proceduri:

DRG:
vr:

Cazul 19_1
Dg.Principal

Proceduri

Dg.secundare

MDC ; DRG
PCCL ; vr

Cazul 20

MI:

Istoric:

Dg.Internare:

Evoluie:

Proceduri
chirurgicale:

Proceduri dg i
terapeutice:

Dg.Final:

Cazul 20 - codificare

Dg.P:
Dg.S:

Proceduri:

DRG:
vr:

Cazul 20_1
Dg.Principal

Proceduri

Dg.secundare

MDC ; DRG
PCCL ; vr