Author Question: The patient is a 29-year-old woman who discovered several large lumps in both breasts when she was ... (Read 23 times)

WhattoUnderstand · **on:** Jun 27, 2018

The patient is a 29-year-old woman who discovered several large lumps in both breasts when she was doing her monthly self-examination. Based on the physical exam, the physician ordered ultrasound and MRI exams of both breasts. The results were showed her bilateral breast implants were leaking.

Dx: Leaking breast implants

Procedures: Bilateral breast Ultrasound and bilateral breasts MRI with and without contrast

Principal/first-listed Dx: ________
Procedures: ________
What will be an ideal response?

Question 2

Patient is 34-year-old female who has four children and she and her husband have decided they are through with childbearing. She has for permanent sterilization and will be having a tubal ligation on an outpatient basis. She has normal menstrual periods and no preexisting medical conditions. The risks and benefits of the procedure were discussed with the patient, including the fact that once the procedure is done, she will no longer be able to conceive children. Sterilization is a permanent procedure. Stating she fully understands the consequences and reiterating that she is refusing other forms of birth control, plans were made for the procedure.

Dx. Permanent sterilization

Procedure: Percutaneous endoscopic tubal ligation

First-listed/principal Dx: ________
Procedure: ________

What will be an ideal response?

swimkari · **Reply #1 on:** Jun 27, 2018

Answer to Question 1

Principal/first-listed Dx: ________
Answer: Leaking breast implants T85.43XA

Procedures: ________
Answer: Either exam can be sequenced first bilateral breast US BH42ZZZ; bilateral MRI of breasts, with and without contrast BH32Y0Z

Answer to Question 2

First-listed/principal Dx: ________
Answer: Encounter for sterilization Z30.2

Procedure: ________
Answer: Bilateral tubal ligation 0UL78ZZ