Microsoft Word - Summary of CASES adult v.2017.docx



Name of resident Year of entry to residency Total number of Cases seen LIST OF ADULT DISEASES: 20 – 59 YEARS OLDTotal Cases listed = 137Tally cases listed on your logbook annually. If the diagnosis is not on this list, add at the end and get the ICD 10 code. Keep this in your Learning Portfolio.CASES ENCOUNTERED/ YEAR12345PROBLEMS RELATED TO LIFESTYLE= 15Tobacco use [ Z72.0]Alcohol use [ Z72.1]Drug use [ Z72.2] abuse of non dependent producing substances [F55]Lack of physical exercise [ Z72.3]Inappropriate diet and eating habits [Z72.4]Non organic insomnia – inadequate quantity or quality of sleep for a prolonged period [ F51.0] Sleep disorders [G47] Insomnia [G47.0]Insomnia due to medical condition (G47.01)High risk sexual behavior [Z72.5]Gambling and betting [Z72.6] Self damaging behavior [Z72.8]Burnout [Z73.0] Lack of relaxation and leisure [ Z73.2]Stress Not elsewhere classified / Physical and mental strain [ Z73.3] Type A behaviour pattern (characterized by unbridled ambition, a need for high achievement,impatience, competitiveness, and a sense of urgency) [Z73.1]Social role conflict [Z73.5] Inadequate social skills [ Z73.4]Problems related to life management difficulty [ Z73. 9]Limitation of activities due to disability[Z73.6] problems related to care provider dependency [ Z74]Problems related to medical facility and other health care – unavailable , unaccessible [ Z76 ]Malingering – person feigning illness with obvious motivation [ Z76.5]NEURO = 10Pain (R52.9)Headaches ; Migrainous headaches (G43)/ Non migrainous headaches (G44) Cluster headache [G44.0]Delirium unspecified [F05.9] Organic emotionally labile (asthenic) disorder [F06.6] Mild cognitive disorder –inassociation with a physical disorder [F06.7]Seizure disorders (R56)Infectious diseases of the CNS = Common bacterial meningitis (G00) Encephalitis [G05]CVA [ I64] / Transient ischemic attacks (G45) Acute stroke, uncomplicated (G46) Intracerebral hemorrhage [I61] Subdural hemorrhage –non traumatic [I62]Subarachnoid hemorrhage [I60]Dementia in Alzheimer early onset (G30.0) Vascular dementia (F01) Multi infarct dementia (F01.1) Unspecified (F03)Polyneuropathy : Guillain Barre (G61.0) Drug induced (G62.0) Alcohol (G62.1) Due to disease (G63) DM polyneuropathy (G63.2) Nutritiondeficiency (G63.4)Nerve root disorders: Trigeminal neuralgia (G50.0) Bell’s palsy (G51.0) Cervical root disorders (G54.2) Phantom limb syndrome (G54.7) Carpal tunnel (G56.0) Mortonmetatarsalgia (G57.6)Postconcussional Syndrome (F07.2)EYE and VISION = 6Conjunctivitis (H10.) Acute atopic conjunctivitis (H10.1) Acute conjunctivitis (H10.3) Blepharoconjunctivitis (H10.5)External diseases of the Eye -Blepharitis (H01)/ Hordeolum (H00) / Chalazion (H00.1)Dacryoadenitis [H04.0] Dry eye syndrome [H04.12] Dacryocystitis acute [H04.32] chronic [H04.41]Error of refraction (H52) Presbyopia [ H52.4] Visual disturbances (H53) )Color vision deficiency (H53.5)Glaucoma [H 40] Hypertensive retinopathy [ H35.03] Diabetic retinopathy [ E08.31]Visual impairment and blindness [H54] Color blindness [H53.5] Night blindness [H53.6]OTORHINOLARYNGOLOGY - Ear, Nose, Oral cavity, Neck = 9Otitis externa (H60.0) Otitis externainfective (H60.3) Otitis externa non infective (H60.5)Acute Serous otitis media (H65.0) Chronic serous otitis media (H65.2) Chronic mucoid OM (H65.3) Acute Suppurative Otitis media (H66.0) Chronic suppurative OM (H66.3)Impacted cerumen (H61.2) Otomycosis (B36.9)Chronic rhinitis (J31) Chronic sinusitis (J32) Nasal polyp (J33)Allergic rhinitis (J30.4) AR Perennial (J30.3) AR Seasonal (J30.2)Vasomotor rhinitis (J30.0)URTI = Acute tonsillitis (J03) / Acute nasopharyngitis (J00) / Pharyngitis (JO2) / Acute laryngitis (J14)Diseases of the oral cavity - Stomatitis (K12) Recurrent oral aphthae (K12.0) Diseases of salivarygland (K11)Benign paroxysmal vertigo (H81.1) Meniere’s Disease (H81.0) Vestibular neuronitis (H81.2)Presbycusis (H91.1) Conductivehearing loss (H90) Noise induced hearing loss (H83.3)SKIN CARE AND DERMA = 16Sunburn (L55) Burns <10% (T31)Cellulitis (L03) Impetigo (L01) Cutaneous abscess , Carbuncle and furuncle (L02) Pyoderma / Erythrasma(L08)Acne [L70] Acne vulgaris [L70.0] Rosacea [L71]Varicella zoster/ Herpes zoster (B02)Scabies (B86)Dermatophytosis (B35) Barbae (B35.0) Unguium (B35.1) Hand(B35.2) Pedis (B35.3) Corporis (B35.4) Pityriasis versicolor (B36)Skin infections – viral: warts (B07)Atopic dermatitis (L20) Seborrheic dermatitis (L21) Dry skin [L85.3]Allergic contact dermatitis (L23) metals (L23.0) adhesives (L23.1) Chemical products (L23.5) Irritant contact dermatitis (L24) detergent(L24.0) solvent (L24.2) cosmetics (L24.3) Plants (L24.7)Insect bites, Urticaria (L50)Psoriasis (L40) Pityriasis rosea [L42] Lichen planus [L43]Vitiligo [L80] café au lait spots [L81.3] Leukoderma [L81.5]Erythema intertrigo [L30.4] Pityriasisalba [L30.5] Granuloma annulare [ L92.0]Androgenic alopecia [L64] Alopecia areata [ L63] Telogen effluvium [ L65.0] Non scarring hair loss [L65.9]Nail disorders [ L60] Paronychia / Candidiasis of nail (B37.2)Corns and callosities [L84] Keloid [L91.0]HEART & CIRCULATION (CARDIAC) = 10Hypertension (I10) HypertensiveHeart Disease [ I11] Secondary Hypertension [ I 15]Angina pectoris ( I20) Unstable Angina [ I 20.0] Prinzmetal Angina [ I20.1]Acute Myocardial Infarction [ I21] Acute subendocardial infarction{121.4]Ischemic heart disease (I20) Atherosclerotic heart disease (I25.1) Chronic Ischemic heart disease [I25]Ischemic cardiomyopathy [I25.5]Cardiomyopathy (I42) Alcohol (I42.6) Drugs etc (I42.7)Heart failure Class I, II (I50) Cor Pulmonale [I27.9]Paroxysmal tachycardia [I47] Supraventricular tachycardia [I47.1] Atrial fibrillation and flutter [ I48 ] Cardiac arrhythmia unspecified [I49.9 ]Acute pericarditis [I30] Pericardial effusion [I31.3] Cardiac tamponade [I31.9]Phlebitis and thrombophlebitis (I80) DVT (I80.2)Varicose veins (I 83) Venous insufficiency , chronic (I87.2)LUNGS & VENTILATION (PULMO) = 8Cough [R05] Hemoptysis [R04.2] Hiccough [R04.6]Bronchial asthma (J45) Status asthmaticus [J46]Acute bronchitis (J20) Chronic bronchitis [J41] Bronchitis due tochemicals fumes and vapors [ J68]Pneumonia (J18) Bacterial pneumonia [J15 ]Viral pneumonia [ J12 ] Aspiration pneumonia [J69.0]Pneumoconiosis unspecified [ J64 ] Respiratory conditions due to inhalation of chemicals, gases, fumes and vapors [ J68 ] Pneumoconiosis due to asbestos and other mineralfibers [J61 ]Pleural effusion, not elsewhere classified [J90 ] Pneumothorax andair leak [J93 ] Other pleural conditions [ J95 ]COPD (J44) Emphysema [J43 ] Simple and mucopurulent chronic bronchitis [ J41 ]Lung/ bronchus cancer [C34]NUTRITION , DIGESTION & GASTRO INTESTINAL TRACT/ HEPATOBILIARY SYSTEM = 14Abdominal and pelvic pain [R10] Epigastric pain [R10.1] flatulence and related conditions [R14]Dyspepsia (K30) Gastroesohageal reflux disease (GERD) (K21) Gastritis (K29)Melena [K92.1] Hematemesis [ K92.0]Paralytic ileus [K56.0] Post operation intestinal obstruction [K91.2] Inguinalhernia [ K40] Femoral hernia [ K41]Irritable bowel syndrome (K58) Functional constipation [K59.0]Hernia [ k46.9] Hemorrhoids, uncomplicated (I84)Acute gastroenteritis (A08)Foodborne staphylococcal poisoning (A05)Cholecystitis ( K81) acute (K81.0) chronic (K81.1) Cholelithiasis (K80) Acute Pancreatitis (K85)Fatty liver [ K76.0] Alcoholic liver disease (K70) Toxic liver disease (K71) Non alcoholic steatohepatitis(K75.8) Chronic hepatitis [K73] Liver cirrhosis [K74]Colon cancer [ C18.9] Liver cancer [ C22.9]Protein Calorie malnutrition of mild and moderate degree [ E44]Nutritional Anemia : Iron deficiency anemia (D50) Vitamin B12 deficiencyMicronutirient deficiency: Vitamin and mineral deficiencyFood Allergy (T78.1) Lactose intolerance (E73)GENITO-URINARY = 8Cystitis, uncomplicated (N30) Acute pyelonephritis, uncomplicated (N10)Vaginitis (N76) Acute cervicitis (N78)Pelvic inflammatory disease (N73)Cervical dysplasia [ N87 ] Carcinoma in situ [ D06 ]Acute epididymitis, uncomplicated (N45) Acute epididimoorchitis, uncomplicated (N45) Acuteepididimoorchitis, uncomplicated (N45) Acute prostatitis (N45)Benign prostatic hypertrophy (N40)Acute urethritis non specific (N34. 1) Urethritis and urethral syndrome [N34]Urolithiasis Calculous of kidney and ureter [ N20 ] Calculus of lower urinary tract [ N21 ]REPRODUCTIVE HEALTH = 6Premenstrual tension syndrome(N94.3) Dysmenorrhea (N94.4) Endometriosis [N80 ]Dysfunctional uterine bleed [N93.8]Menopause and female climacteric states (N95)Hyperemesis gravidarum (O21)Single spontaneous delivery (O80)Unspecified lump in the breast (N63)Unspecified sexual dysfunction (F52.9) Erectile dysfunction [ N52]MUSCULO-SKELETAL = 8Myalgia (M79.1) Muscle strain (M62.1)Chondrocostal junction syndrome (Tietze) (M94)Low back pain (M54.5) Scoliosis, uncomplicated (M41)Osteoarthritis, uncomplicated (M13.9)Rheumatoid arthritis, uncomplicated (M05)Gout, uncomplicated (M10)Osteoporosis (M81)Unspecified multiple injuries [T07] Fracture [S40/ S52/ S72/ S82/ S92]ENDOCRINOLOGY/ METABOLIC/ NUTRITIONAL = 8Obesity (E66)Diabetes mellitus type II (E11)Hyperthyroidism, uncomplicated (E05)Hypothyroidism, uncomplicated (E02)Nontoxic goiter (E04)Hyperlipidemia, unspecified (E78.5) Hypercholesterolemia (E78)Mixed disorder of acid-base balance (E87.4) Acidosis (E87.2) Alkalosis (E87.3) Electrolyte imbalance : Hypokalemia (E87.5)Hyperkalemia(E87.5) Fluid overload (E87.7)Polycystic Ovarian Syndrome [E28.2]INFECTIOUS = 11Influenza (J11) Influenza like Illness [J11.1] Viral agents as cause of disease [B97.89]Herpes Simplex (B02)Parasitism: Ascariasis (B76) / Hookworm (B77)/ Trichuriasis (B79) / Enterobiasis (B80)/ Intestinal parasitism, unspecified (B82.9)Tuberculosis : Respiratory organs(A15) Nervous system [ A17] Other organs [A18] Miliary TB [A19]Malaria, uncomplicated (B54) Dengue fever (A90)Typhoid Fever (A01) Leptospirosis (A27)Rabies (A82) Dog bite [ W54 ] Rat bite [ W53 ] Animal bite [T14.1] Snake bite [T 63.0]HIV disease [B20]Viral hepatitis A (B15)/ Viral hepatitis B (B16)Amoebiasis (A06)/ GiardiasisSepsis [A 41.9] Septic shock [ R57.2]IMMUNOLOGIC = 2Anaphylactic shock unspecific [ T78.2] Angioneurotic edema [T78.3]Food allergy : shellfish [T78.02] fish [T78.03] vegetables [T78.04] nuts andseeds [T78.05] milk and dairy products [t78.07]POISONS & TOXICOLOGYToxic effects of pesticides [ T60] Alkalis and acid (T54.2)Poisoning by drugs , medicaments and other biological products [ T36 – T 50 ] Accidental Poisoning =Salicylate (T39) / INH (T37.1)MENTAL & EMOTIONAL DISORDERS = 6Acute stress reaction [F43.0] Post traumatic stress reaction [F43.1] Adjustment disorder [ F43.2]Depressive episodes (F32)Anxiety disorders (F41.9) Phobic anxiety [ F40]Dissociative (conversion) disorders (F44) / Somatization disorders (F45) Eating disorders (F50)Bipolar Disease [ F31] Schizophrenia [ F20 ] Brief psychotic disorder [ F23]Adult and child abuse , neglect and other maltreatment [T74][Additional] NOT LISTED please look for ICD 10 code ................
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