guide to medical diagnosis

7/26/2019 Guide to Medical Diagnosis

1/13

GUIDE TO MEDICAL DIAGNOSIS COMPATIBLE WITH ICD-10(International Statistical Classifcation o Diseases and Related Health Problems, WHO 1992

PHYSICIANS USUAL

ADMITTING OR FINALDIAGNOSIS

ICD 10 DIAGNOSIS ICD!1"

C#$%&OR'

WILL FALL UNDER:

(or SPPH statisticalrecordin) o ten leadin)

diseases

*alaria Protozoa D!"#a"#" B$0-B%&

*#+#RI#*alaria indicate i alci-ar.m

or /i0a, *alariae or *ied

indicate i .ncom-licated or

Se0ere Cerebral *alaria

Plasmodium Falciparum

*alaria

3"

Plasmodium Vivax*alaria 31

Plasmodium Malariae *alaria 32

4ns-ecifed *alaria 35

A'(t# U))#r R#")!rator*

Tra't I+,#'t!o+"

A'(t# U))#r R#")!rator*

Tra't I+,#'t!o+"

00-00%

(--36

4PP%R R%SPIR#$OR' $R#C$

I7%C$IO7

#c.te 4--er Res-irator8 $ract

Inection (#4RI or

4PP%R R%SPIR#$OR' $R#C$

I7%C$IO7 (4R$I or

#c.te $onsillo-har8n)itis (#$P

#c.te 7aso-har8n)itis

(common cold

""

#c.te Sin.sitis "1

#c.te Phar8n)itis "2

#c.te $onsillitis ":

#c.te +ar8n)itis ; $racheitis "5

#c.te Obstr.cti0e +ar8n)itis

(Cro.- ; %-i)lottitis

"3

#c.te 4--er Res-irator8

Inections o *.lti-le ;

4ns-ecifed Sites

"6

Rhinitis (aller)ic :"

I+.(#+za / P+#(o+!a I+.(#+za / P+#(o+!a 10-1

P7%4*O7I#

In?o -ne.monia or other

res-irator8 maniestations

1"@"!1"@A

In


2/13

Pne.monia?roncho-ne.monia

Comm.nit8 #cB.ired

Pne.monia +o> Ris?*od

Ris?Hi)h Ris acterial

Pne.monia, s-eci8 or)anism i

-ossible indicate cate)or8 (+o>Ris Hi)h Ris based on

Protocol

Pne.monia d.e to

streptococcus pneumoniae

1:

Pne.monia d.e to H.

infuenzae

15

acterial -ne.monia, not

else>here classifed

13

acterial -ne.monia,

.ns-ecifed

13@9

+o>er Res-irator8 $ract

Inection

Ot2#r a'(t# o3#r

r#")!rator* tra't !+,#'t!o+"

2"!22

+OW%R R%SPIR#$OR' $R#C$

I7%C$IO7#c.te ronchitis 2"

#c.te ronchiolitis 21

Chronic Obstr.cti0e P.lmonar8

Disease (COPD %m-h8sema

0s ronchiectasis

C2ro+!' Lo3#r R#")!rator*

I+,#'t!o+

&0-&4

(--3E COPD (CHRO7IC

OS$R4C$I/% P4+*O7#R'

DIS%#S%

%m-h8sema 5:

ronchiectasis 5Eronchial #sthma in #c.te%acerbation or Controlled7e> ClassifcationF

Intermittent

*ild!*oderatePersistent

Se0ere Persistent

ronchial #sthma 53 RO7CHI#+ #S$H*#

Stat.s #sthmatic.s Stat.s #sthmatic.s

P.lmonar8 $.berc.losis, indicate

Classifcation ; i treatment startedindicate date started

or -resent treatment -haseCa"" 0 : 7o e-os.re 7o Disease

Ca"" 1 : %-os.re 7o si)ns o inection

Ca"" 5 :+atent Inection 7o Disease

Ca"" 6 :Disease Clinicall8 acti0e

Res-irator8 $.berc.losis,

indicate i confrmed b8

s-.t.m microsco-8 or not

#13! #19

(--@ 112 P4+*O7#R' $4%RC4+OSIS

(P$


3/13

Ca"" & :Disease Clinicall8 #cti0eCa"" $ :S.s-ected Disease Dia)nosis

Pendin)

H*)#rt#+"!7# D!"#a"#" H*)#rt#+"!7# D!"#a"#" I10-I1$H'P%R$%7SIO7

H8-ertension, Controlled or

4ncontrolled

Sta)e I

Sta)e II? Se0ere

%ssential ( Primar8

H8-ertension

I1"

Secondar8 H8-ertension I13

H8-ertensi0e Cardio0asc.lar

Disease

H8-ertensi0e 7e-hro-ath8

H8-ertensi0e Renal Disease I12 H'P%R$%7SI/%

C#RDIO/#SC4+#R DIS%#S%

H8-ertensi0e Heart ; Renal

Disease

I1:

H8-ertensi0e Heart Disease I11

I"'2#!' H#art D!"#a"# I"'2#!' H#art D!"#a"#" I150-15$

ISCH%*IC H%#R$ DIS%#S%

#n)ina Pectoris? 4nstable

#n)ina

#n)ina Pectoris I2"

#c.te *8ocardial Inarction #c.te *8ocardial Inarction I21

C#r#8ro7a"'(ar D!"#a"#"9Stro#;

C#r#8ro7a"'(ar D!"#a"#" I6"!69C%R%RO/#SC4+#R

DIS%#S%S (C/D

S.barachnoid Hemorrha)e S.barachnoid Hemorrha)e I6"

Intracerebral Hemorrha)e?leed Intracerebral Hemorrha)e I61

Cerebral

Inarction?Ischemia?Inarct

Cerebral Inarction I6:

D!arr2#a< AGE I+t#"t!+a I+,#'t!o("

D!"#a"#"

A00-A0=

#c.te Diarrhea? #c.te

&astroenteritis indicate le0el o

Deh8dration (Some?*ild,

*oderate or Se0ere, indicate

ca.sati0e a)ent i identifed

Diarrhea ; &astroenteritis o

-res.med Inectio.s Ori)in

#"9 DI#RRH%# ;

S$RO%7$%RI$IS O

PR%S4*%D I7%C$IO4S

ORI&I7

Cholera Cholera #"" CHO+%R#


4/13

$8-hoid? Parat8-hoid e0er

Inection

$8-hoid ; Parat8-hoid e0ers #"1 $'PHOID ; P#R#$'PHOID

%/%RS

Shi)ellosis Shi)ellosis #": SHI&%++OSIS

#moebiasis #moebiasis #"6 #*O%I#SIS

S!+< S(8'(ta+#o(" T!""(#

I+,#'t!o+"

I+,#'t!o+" o, t2# S!+ a+>

"(8'(ta+#o(" t!""(#

+""!+99

I7%C$IO7S O $H% SGI7 ;

S4C4$#7%O4S $ISS4%Im-eti)o Im-eti)o +"1

C.taneo.s #bscess, .r.ncle,

Carb.ncle

C.taneo.s #bscess, .r.ncle

; carb.ncle

+"2

Cell.litis Cell.litis +":

D#rat!t!" / E'z#a D#rat!t!" / E'z#a L50-L60D%R*#$I$IS ; %C%*#

Dermatitis? %c=emato.s

Dermatitis, indicate t8-e

#to-ic Dermatitis +2"

Seborrheic dermatitis +21

Dia-er (na-in dermatitis +22

#ller)ic Contact Dermatitis +2:

Irritant Contact Dermatitis +25

%oliati0e dermatitis +26

Pr.rit.s +29

other Dermatitis +:"

Pa)(o"?(ao(" D!"or>#r" Pa)(o"?(ao("

D!"or>#r"

+5"!+53

PSORI#SIS

Psoriasis Psoriasis +5"

Para-soriasis Para-soriasis +51

Urt!'ar!a / Er*t2#a Urt!'ar!a / Er*t2#a L$0-L$&

4R$IC#RI#4rticaria 4rticaria +3"

%r8thema m.ltiorme %r8thema m.ltiorme +31


5/13

%r8thema nodos.m %r8thema nodos.m +32

@!ra I+,#'t!o+" o, C#+tra

N#r7o(" S*"t#

A0-=

#c.te Poliom8elitis #c.te Poliom8elitis #A" PO+IO*'%+I$IS

#cti0e Rabies Inection,

s8m-tomatic

Rabies #A2 R#I%S

/iral *enin)itis /iral *enin)itis #AE

Art2ro)o>-8or+# 7!ra

,#7#r" / 7!ra 2#orr2a!'

,#7#r"

A=0-A==

Den).e e0er (ClassicalDen).e

Den).e e0er (ClassicalDen).e

#9" D%7&4% %/%R I7%C$IO7

Den).e hemorrha)ic e0er Den).e hemorrha)ic e0er #91 D%7&4% H%*ORRH#&IC

%/%R

@!ra I+,#'t!o+" 3< "!+ /

('o(" #8ra+# #"!o+"

B00-B0=

Her-es0iral?Her-es sim-le

Inection

Her-es0iral?Her-es sim-le

Inection

"" H%RP%S /IR4S I7%C$IO7

/aricella (Chicen -o /aricella (Chicen -o "1

oster (Her-es =oster oster (Her-es =oster "2

*easles?/iral %anthem *easles "3 *%#S+%S /IR4S I7%C$IO7

R.bella (&erman *easles R.bella (&erman *easles "6

D!"#a"#" o, t2#

#"o)2a(" "toa'2 a+>

>(o>#+(

50-61

&%RD &astroeso-ha)eal Re


6/13

Pe-tic 4lcer, site 4ns-ecifed G2E

&astroJeJ.nal 4lcer G2A

#c.te? Chronic &astritis &astritis ; D.odenitis G29 S$RI$IS? D'SP%PSI#

D8s-e-sia D8s-e-sia G:"

URINARY TRACT INFECTION

indicate site i -ossible indicate

i Com-licated or

4ncom-licated

D!"#a"#" o, t2# G#+!to-

Ur!+ar* S*"t#

N00-N==

P8elone-hritis iner .rinar8 tract 721

Calc.l.s o .rinar8 tract in

diseases classifed else>here

722K

A8ort!o+

#O& in >ees, O scorin)

e)@1A >ees #O&, &2 P1 (1!"!1!

1 -l.sF

Pr#+a+'* 3!t2 A8ort!7#

O(t'o#

O00-O0

PR%&7#7C' WI$H #OR$I/%

O4$CO*%S

%cto-ic Pre)nanc8 %cto-ic Pre)nanc8 O""

H8datidiorm mole H8datidiorm mole O"1

#bortion, S-ontaneo.s, Se-tic S-ontaneo.s #bortion O":


7/13

or non!se-tic, Com-lete or

Incom-lete

Other #bortion O"5

H8-o0olemic shoc or #c.te

blood loss secondar8 to

Com-lications ollo>in)

abortion and ecto-ic ; molar

-re)nanc8

O"A

H*)#rt#+"!7# D!"or>#r" !+

Pr#+a+'*

H*)#rt#+"!7# D!"or>#r" !+

Pr#+a+'*

O10-O1%

H'P%R$%7SI/% DISORD%RS

I7 PR%&7#7C'Pre)nanc8 4terine, indicate

#O&, O score -l.sF

H8-ertension (Pre!eistin)

Pre!eistin) h8-ertension

com-licatin) -re)nanc8,

childbirth ; -.er-eri.m

O1"

Pre)nanc8 4terine, indicate

#O&, O score -l.sF Pre)nanc8!

ind.ced H8-ertension (PIHPre!eclam-sia

&estational H8-ertension >?

or >?o -rotein.ria

O1:!O15

%clam-sia %clam-sia O13

4ns-ecifed *aternal

H8-ertension

O16

Pre)nanc8 4terine, indicate

#O&, O score -l.sF

Mat#r+a >!"or>#r"

)r#>o!+a+t* r#at#> to

)r#+a+'*

O50-O5= *#$%R7#+ DISORD%RS I7

PR%&7#7C'

Intra-art.m Hemorrha)e Hemorrha)e in earl8

-re)nanc8

O2"

H8-eremesis &ra0idar.m %cessi0e /omitin) in

Pre)nanc8

O21

4rinar8 $ract Inection Inections o )enito!.rinar8

tract in -re)nanc8

O2:

D*, &estational Diabetes Diabetes *ellit.s in

-re)nanc8

O25

Mat#r+a Car# r#at#> tot2# ,#t(" / a+!ot!' 'a7!t*

/ )o""!8# >#!7#r*

)ro8#"

O60-O&

%$#+ ; #*7IO$IC C#/I$'

R%+#$%D D%+I/%R'

PRO+%*S$>in Pre)nanc8, *.lti-le

&estation

*.lti-le &estation O:"

Pol8h8dramnios Pol8h8dramnios O5"


8/13

Premat.re R.-t.re o

*embranes (PRO*

Premat.re R.-t.re o

*embranes

O52

Placental Disorders Placental Disorders O5:

Placenta Pre0ia Placenta Pre0ia O55

#br.-tio Placenta #br.-tio Placenta O53

Post!*at.rit8, Post!Datism Prolon)ed Pre)nanc8 O5A

Co)!'at!o+" o, La8or

a+> D#!7#r*

O%0-O4$

CO*P+IC#$IO7S O +#OR ;

D%+I/%R'Preterm Deli0er8 Preterm Deli0er8 O6"

ailed Ind.ction o +abor ailed Ind.ction o +abor O61

Prolon)ed +abor +on) +abor O6:

Prolon)ed labor d.e to

*al-resentation (reech

Presentation, $rans0erse +ie

Obstr.cted +abor d.e to

*al-osition and

mal-resentation o et.s

O65

Ce-halo!-el0ic dis-ro-ortion

(CPD

Obstr.cted labor d.e to

maternal -el0ic abnormalit8

O63

etal Distress +abor ; deli0er8 com-licated

b8 etal distress

O6A

Cord Coil? Cord com-lications +abor ; deli0er8 com-licated

b8 .mbilical cord

com-lications

O69

Post-art.m Hemorrha)e Post-art.m Hemorrha)e OE2

Retained Placenta ;

*embranes

Retained Placenta ;

*embranes

OE:

Other com-lications, not

else>here classifed

OE3

$erm, ce-halic, deli0ered 0ia

7S/D (7ormal S-ontaneo.s

/a)inal Deli0er8 to a +i0e ab8

&irl or o8, indicate W (birth

>ei)ht, #PR score

D#!7#r* O0-O&

7S/D Sin)le S-ontaneo.s deli0er8 OA" 7OR*#+ SPO7$#7%O4S

/#&I7#+ D%+I/%R'


9/13

orce-s deli0er8? %traction Sin)le deli0er8 b8 orce-s ;

0ac..m etractor

OA1

C%S#R%#7 D%+I/%R' Sin)le deli0er8 b8 cesarean

section

OA2 C%S#R%#7 S%C$IO7

*.lti-le Deli0er8 *.lti-le Deli0er8 OA5 *4+$IP+% D%+I/%R'

Co)!'at!o+" r#at#> to

t2# )(#r)#r!(

O$-O=5

P4%RP%R#+ CO*P+IC#$IO7S

P.er-eral se-sis P.er-eral se-sis OA3

Obstetric embolism Obstetric embolism OAA

Com-lications o -.er-eri.m,

not else>here classifed

O9"

7e>bornF Patholo)ic or non!

-atholo)ic

7on!Patholo)icF +i0e, term,

ab8 bo8 or &irl, deli0ered 0ia

7S/D or cesarean to (indicate

maternal O score indicate

W (irth >ei)ht, #PR score

7o mention 7%WOR7, 7O7!

P#$HO+O&IC

Co+>!t!o+" or!!+at!+ !+

t2# )#r!+ata )#r!o>

P00-P=%

7%WOR7, P#$HO+O&IC

7%WOR7, P#$HO+O&IC

birth inJ.r8 to (indicate site irth tra.ma P"3!P"A

Intra.terine h8-oia P2"

irth as-h8ia P21

Res-irator8 Distress o the

ne>born

P22

Con)enital Pne.monia P2:

*econi.m Stainin)? *econi.m

#s-iration S8ndrome

7eonatal as-iration

s8ndromes

P25

Con)enital 0iral diseases P:3

7eonatal Se-sis, se-ticemia acterial Se-sis o ne>born P:6

H8dro-s etalis d.e to

hemol8tic disease

P36


10/13

Gernicter.s P3E

7eonatal Ja.ndice

7eonatal a.ndice d.e to

other ecessi0e hemol8sis

P3A

7eonatal a.ndice rom other

; .ns-ecifed ca.ses

P39

Con)enital malormations o the

brain ; s-inal cord

Con)enital *alormations o

the ner0o.s s8stem

L""!L"E

#nence-hal8 ; similar

malormations

#nence-hal8 ; similar

malormations

L""

%nce-halocele %nce-halocele L"1

*icroce-hal8 *icroce-hal8 L"2

Con)enital h8droce-hal.s Con)enital h8droce-hal.s L":

TRAUMA I+(r* Po!"o+!+ / '#rta!+

ot2#r 'o+"#?(#+'#" o,

#t#r+a 'a("#"S00-T=

Re)ardless o location, t8-e

and de)ree o inJ.r8?inJ.riesF

classi8 as

$R#4*#

1@ #CCID%7$S

#@ $R#7SPOR$ #CCID%7$S

or

@ 7O7!$R#7SPOR$

#CCID%7$S @1 I$$%7 OR S$R4CG

' DO&

@2 I$$%7 ' R#$

@: I$$%7 ' C#$

@5 #++S

@3 all others

2@ I7$%7$IO7#+ S%+!H#R*

:@ #SS#4+$S

7oteF Do)bite cases are

considered as $ra.ma .nder

7on!trans-ort accidents b.t

shall be acco.nted orse-aratel8 or recordin)

-.r-oses o Hos-ital

cases?-atients recei0in) -re

; -ost!e-os.re -ro-h8lais

or Rabies

It is the res-onsibilit8 o the

Indicate t8-e, location and

ca.se

$'P%F

S()#r'!a(abrasion,blister,

cont.sion incl.din) br.ise ;

hematoma, insect bite (non!

0enomo.s

O)#+ Wo(+> ( incl.des

animal bite, c.t, laceration,

-.nct.re >o.nd >? or >?o

-enetratin) orei)n bod8,

a0.lsion

Fra't(r# (incl.des o-en or

closed, dislocated,

dis-laced,commin.ted

Cr("2!+ !+(r*, a7("!on or

Tra(at!' A)(tat!o+

C#4S% (Secondar8 toF1 A''!>#+t"

#@ TRANSPORT ACCIDENTS

classi8 0ictim as

-assen)er?occ.-ant, dri0er or

-edestrian and t8-e o 0ehicle

@ NON-TRANSPORT

ACCIDENTSF

InJ.ries to the head S""!S"9

InJ.ries to the nec S1"!S19

InJ.ries to the thora S2"!S29

InJ.ries to the abdomen,lo>er

bac, l.mbar s-ine ; -el0is

S:"!S:9

InJ.ries to the sho.lder ;

.--er arm

S5"!59

InJ.ries to the elbo> ;

orearm

S3"!S39

InJ.ries to the >rist ; hand S6"!S69

InJ.ries to the hi- ; thi)h SE"!SE9

InJ.ries to the nee ; lo>er

le)

SA"!SA9

InJ.ries to the anle ; oot S9"!S99

InJ.ries in0ol0in) m.lti-le

bod8 re)ions

$""!$"E


11/13

a@ alls

b@ %-os.re to animate or

inanimate mechanical

orces

c@ dro>nin) ; s.bmersion

5 I+t#+t!o+a "#,-2ar6 A""a(t inJ.ries in?

intent to inJ.re or ill b8 an8

means a0oid .se o

Mma.lin)Ndo not or)et

Malle)edl8N

or all tra.ma cases, medico!

le)al or not, al>a8s note nat.re,

date, time and -lace o inJ.r8

( DOI,DOI,$OI,POI

Please be elaborate es-eciall8on the 7at.re o InJ.r8

%#*P+%SF

7OIF /ictim alle)edl8 assa.lted

>ith a stone thro>n hittin)

-atient head

7OIF *otorc8cle rider alle)edl8

inJ.red

in collision >ith -edestrian or

animal

7OIF /ictim alle)edl8 ell rom

the bed?chair?.rnit.re?

ladder?tree

7OIF /ictim alle)edl8 sla--ed on

the chee b8 -artner?

-arent?s-eci8 b8 >hom

S#*P+% DI#&7OSISF

O-en >o.nd(laceration, +et

#rm secondar8 to accidental

contact >ith a shar- )lass

*.lti-le InJ.riesF head, tr.n,

etremities secondar8 to$rans-ort #ccident? all?#ssa.lt

b8 .nno>n -erson

*edical Records section to

chec on the 7at.re o InJ.r8

rom the Charts or the

-.r-ose o .rther

classifcation based on ICD

1"@

Tra+")ort A''!>#+t" @01-@==

Ot2#r #t#r+a Ca("#" o,

A''!>#+ta I+(r*

W00-$=

alls W""

%-os.re to !+a+!at#

mechanical orcesF

W2"!W59

orei)n bod8 or obJect

enterin) thro.)h sin

W53

%-os.re to a+!at#

mechanical orcesF

W3"!W65

Hit, str.c, iced, t>isted,

bitten or scratched b8 another-erson (ecl.des assa.lt A3!

'"9, str.c b8 obJects W2"!

22

W3"

itten b8 rat W3:

itten or Str.c b8 do) W35

itten or str.c b8 other

mammals (cat

W33

#ccidental dro>nin) ;

s.bmersion

W63!WE5

I+t#+t!o+a "#,-2ar %0-&

A""a(t incl.des homicide,

inJ.ries in?intent to inJ.re or

ill

$-Y0=

#ssa.lt b8 dr.)s, corrosi0e

s.bstances, -esticides, )ases

; 0a-o.rs

A6!AA

#ssa.lt b8

han)in),stran).lation ;

s.ocation

91

#ssa.lt b8 dro>nin) ;

s.bmersion

92

#ssa.lt b8 hand).n 9:!96


12/13

dischar)e, ri


13/13

stenely o. manuel, md9/25/10

guide to medical diagnosis

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