guide to medical diagnosis
TRANSCRIPT
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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
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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' $4%RC4+OSIS
(P$
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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#
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$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$IC#RI#4rticaria 4rticaria +3"
%r8thema m.ltiorme %r8thema m.ltiorme +31
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%r8thema nodos.m %r8thema nodos.m +32
@!ra I+,#'t!o+" o, C#+tra
N#r7o(" S*"t#
A0-=
#c.te Poliom8elitis #c.te Poliom8elitis #A" PO+IO*'%+I$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$IO7
R.bella (&erman *easles R.bella (&erman *easles "6
D!"#a"#" o, t2#
#"o)2a(" "toa'2 a+>
>(o>#+(
50-61
&%RD &astroeso-ha)eal Re
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Pe-tic 4lcer, site 4ns-ecifed G2E
&astroJeJ.nal 4lcer G2A
#c.te? Chronic &astritis &astritis ; D.odenitis G29 S$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":
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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"
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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'
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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
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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
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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
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dischar)e, ri
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stenely o. manuel, md9/25/10