Icd 10 Code Diagnosis Case Study

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• Identify ONE Primary with ICD 10 code diagnosis given the information in part one and part two together. Include the rationale and a reference for your diagnoses. • Migraine Headaches (G43.0)- Migraine headaches are the most common type of headaches in the pediatric population. Diagnostic criteria can be complex in pediatrics. Patients often experience headaches that are bilateral and located in the frontal temporal region. It is associated with pulsating pain, nausea, photophobia, phonophobia and aggravated with activity. (Pathostatement) The pathophysiology is often elusive. The cause is often neurovascular and take place in the brain. A type of neuron event can cause an imbalance in the trigeminal system causing inflammation. This type…show more content…
They are occuring 1-2 times a week. He does not have aura. He is unable to continue tasks when they start. He is also having nausea with the headaches. Light hurts his eyes, and sleep seems to help at times. The patient is not getting enough sleep at night and he is having trouble going to sleep. He describes the pain as pulsating pain in the temporal region. There is no identified trigger. • Identify any relevant secondary diagnoses (differential diagnoses are eliminated in part two). Insomnia (ICD 10 G47.00)-(Pathostatement) Insufficent sleep that causes deficits in waking hours (Hysing, Pallesen, Stormark, Lundervold, & Sivertsen, 2013). Rational: Patient states that he has trouble falling asleep. He only sleeps for 5-6 hours. • Design a first-line treatment plan for your primary diagnoses based on current evidence-based journal articles. 1. Keep a headache journal- log headache days, any triggers, nausea, visual disturbance, and duration of headaches. 2. Triptans are considered first line when OTC medication has not worked. Guidelines recommend the use of combination therapy with triptans and analgesics such as Acetaminophen (Kennis, Kernick, & O 'Flynn, 2013). The patient has not had relief from Ibuprofen or
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