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PIISA 12

The patient has a history of mild left knee pain after physical activity. The patient presents with acute left knee swelling, warmth, and limited range of motion. MRI shows joint effusion and blood in the left knee joint. Hemarthrosis, left knee. The patient presents with acute left knee swelling, warmth, and limited range of motion. MRI shows joint effusion and blood in the left knee joint. Patient reports no history of trauma or bleeding disorders. No signs of infection present. Joint stability is intact. RICE protocol (Rest, Ice, Compression, Elevation) advised. Prescribed pain management and follow-up with a hematologist. Patient responded well to treatment and was discharged with instructions for home care and a follow-up appointment in two weeks. 45 Male Caucasian ICD Code: M25062

The patient has a history of osteoarthritis in the left shoulder. The patient presents with swelling, tenderness, and limited range of motion in the left shoulder. MRI of the left shoulder shows an effusion without signs of infection or other abnormalities. Effusion, left shoulder. The patient presents with swelling, tenderness, and limited range of motion in the left shoulder. MRI confirms the presence of an effusion without signs of infection, supporting the diagnosis of effusion in the left shoulder. The patient reports worsening pain upon movement and difficulty performing daily activities due to the left shoulder effusion. Physical examination reveals warmth and swelling in the left shoulder joint. Treatment includes aspiration of the effusion, intra-articular corticosteroid injection, and a referral for physical therapy. The patient responded well to treatment, with decreased pain and improved range of motion. Discharged with a recommendation for follow-up with the orthopedic specialist in two weeks. 67 Female Caucasian ICD Code: M25412

The patient has a history of occasional elbow pain and swelling after engaging in repetitive manual tasks at work. No history of trauma or injury to the right elbow. The patient presents with pain, swelling, and limited range of motion in the right elbow. The swelling is noticeable, with visible fullness around the joint area. X-ray of the right elbow shows joint effusion without any signs of fractures or dislocations. Effusion, right elbow. The joint effusion in the right elbow is causing pain, swelling, and limited range of motion. The patient denies any recent trauma or injury to the area. The patient reports that the symptoms started insidiously and have been progressively worsening over the last few weeks. Physical examination reveals warmth around the elbow joint with tenderness on palpation. Prescribed NSAIDs for pain management, advised rest, ice, compression, and elevation (RICE protocol) for home care. Follow-up appointment scheduled in two weeks for reevaluation. 42 Male Caucasian ICD Code: M25.421

The patient has a history of osteoarthritis in the left elbow. The patient presents with swelling, warmth, and limited range of motion in the left elbow. MRI of the left elbow shows significant effusion without any signs of trauma or infection. Effusion, left elbow. The patient presents with swelling, warmth, and limited range of motion in the left elbow. MRI confirms significant effusion without signs of trauma or infection. The patient reports increased pain with movement and stiffness in the left elbow. Physical examination reveals visible swelling and warmth in the left elbow joint. Prescribed NSAIDs for pain management and advised rest, ice, and elevation of the left elbow. Follow-up scheduled in two weeks for reevaluation. The patient responded well to treatment and was discharged with instructions to continue NSAIDs and monitor elbow range of motion. Advised to follow up if symptoms persist or worsen. 58 Female Caucasian ICD Code: M25422

The patient has a history of mild osteoarthritis in the left wrist. The patient complains of swelling, stiffness, and mild pain in the left wrist. X-ray of the left wrist shows soft tissue swelling and joint effusion. Effusion, left wrist. Verbatim_EHR_quote_justifying_the_code: 'Patient presents with swelling, stiffness, and mild pain localized to the left wrist. X-ray confirms soft tissue swelling and joint effusion in the left wrist.' On examination, there is visible swelling in the left wrist with limited range of motion. No signs of infection or trauma. Prescribed NSAIDs for pain management and advised wrist rest and ice application. Patient responded well to treatment, swelling reduced, pain decreased, and range of motion improved. Discharged with advice for home care and follow-up in two weeks. 57 Female Caucasian ICD Code: M25.432

The patient has a history of osteoarthritis in the right hip. The patient presents with pain, swelling, and limited range of motion specifically localized to the right hip joint. X-ray of the right hip shows joint effusion without evidence of ankylosis or hemarthrosis. Effusion, right hip (M25.451) Physical examination reveals tenderness over the right hip joint with no signs of contracture or ankylosis. The patient reports discomfort exacerbated by movement. Prescribed NSAIDs for pain management and advised on hip-strengthening exercises. Patient responded well to treatment, pain reduced, and range of motion improved. Advised to follow up if symptoms persist. 68 Female Caucasian ICD Code: M25.451

The patient has a history of osteoarthritis in the right knee. The patient presents with pain, swelling, and limited range of motion in the right knee. MRI of the right knee shows significant effusion without signs of ankylosis or hemarthrosis. Effusion, right knee. The patient presents with pain, swelling, and limited range of motion in the right knee. MRI confirms significant effusion without ankylosis or hemarthrosis. The patient reports gradual onset of symptoms over the past month. Physical examination reveals warmth and tenderness over the right knee joint with visible swelling. No signs of infection are noted. The patient is prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management and advised to undergo physical therapy for range of motion exercises. The patient responded well to treatment and was discharged with instructions for home exercises and a follow-up appointment in two weeks. 65 Female Caucasian ICD Code: M25.461

The patient has a history of mild osteoarthritis in the right ankle. The patient presents with localized swelling, warmth, and limited range of motion in the right ankle. X-ray of the right ankle shows joint effusion without any signs of fracture. Effusion, right ankle (ICD-10-CM code M25.471): Effusion in the right ankle joint causing localized swelling, warmth, and limited range of motion. The patient reports a recent history of trauma to the right ankle, which could have triggered the effusion. No signs of infection or inflammatory arthritis observed. Prescribed NSAIDs for pain and inflammation, advised R.I.C.E. protocol (Rest, Ice, Compression, Elevation) and follow-up with a physical therapist for range of motion exercises. The patient was discharged in stable condition with instructions to continue medications and therapy. Follow-up appointment scheduled in two weeks to assess progress. 58 Female Caucasian ICD Code: M25.471

The patient has a history of mild osteoarthritis in the left ankle. The patient presents with pain, swelling, and limited range of motion in the left ankle. X-ray of the left ankle shows joint effusion but no signs of fracture. Effusion, left ankle. Verbatim: 'Patient presents with pain, swelling, and limited range of motion in the left ankle. X-ray confirms joint effusion without fracture.' On examination, there is tenderness and warmth over the left ankle joint. No signs of infection are noted. Prescribed NSAIDs for pain management and advised rest, ice, compression, and elevation (RICE protocol). Physical therapy referral made. Patient responded well to treatment, pain reduced, and swelling decreased. Discharged with instructions for home care and follow-up with the orthopedist in two weeks. 55 Female Caucasian ICD Code: M25.472

The patient has no history of joint-related issues or chronic conditions. The patient presents with persistent pain in a joint without any specific location or side mentioned. X-ray of the joint shows no signs of effusion or structural abnormalities. Pain in unspecified joint: The patient presents with persistent pain in a joint without any specific location or side mentioned, ruling out codes that specify laterality or a particular joint. The patient reports pain on movement but cannot pinpoint the exact location. Physical examination reveals tenderness in a joint without signs of inflammation or effusion. Prescribed acetaminophen for pain management and advised on joint rest and gentle exercises. The patient responded well to treatment, with a decrease in pain intensity. Advised to follow up if symptoms persist. 45 Female Caucasian ICD Code: M2550

The patient has no history of joint pain or arthritis except for the current complaint of pain in the right shoulder. The patient presents with localized pain in the right shoulder, aggravated by movement and relieved by rest. No other joint pain reported. X-ray of the right shoulder shows no signs of fractures or dislocations, confirming soft tissue involvement. Pain in right shoulder. Verbatim EHR quote justifying the code: 'The patient reports significant pain localized in the right shoulder joint, with tenderness on palpation and limited range of motion.' Physical examination reveals no swelling or redness in the right shoulder. The patient describes the pain as a dull ache, rating it 7/10 on the pain scale. Prescribed NSAIDs for pain management and advised rest, ice, and gentle shoulder exercises. Follow-up scheduled in two weeks. The patient responded well to treatment, with decreased pain intensity and improved range of motion in the right shoulder upon discharge. 56 Female Caucasian ICD Code: M25511

The patient has a history of occasional shoulder pain due to overuse during sports activities. The patient presents with sharp pain localized to the left shoulder, aggravated by movement and relieved by rest. X-ray of the left shoulder shows no signs of fractures or dislocations, ruling out traumatic causes of pain. Pain in left shoulder: The patient presents with sharp pain localized to the left shoulder, aggravated by movement and relieved by rest. The patient reports no history of recent trauma or injury to the left shoulder. Physical examination reveals tenderness over the left shoulder joint with no signs of swelling or redness. Prescribed NSAIDs for pain management and advised rest and ice application. Physical therapy sessions scheduled to improve shoulder mobility and strength. The patient responded well to treatment and reported decreased pain intensity. Discharged with instructions for home exercises and a follow-up appointment in two weeks. 45 Female Caucasian ICD Code: M25512

The patient has a history of occasional shoulder pain due to overuse during sports activities. The patient presents with persistent pain in the right shoulder, exacerbated by movement and relieved by rest. There is no history of recent trauma or injury to the shoulder. X-ray of the right shoulder shows no signs of fractures or dislocations. MRI reveals no structural abnormalities in the shoulder joint. Pain in unspecified shoulder: The patient presents with persistent pain in the right shoulder, exacerbated by movement and relieved by rest. No specific cause identified. The patient reports a gradual onset of shoulder pain without any recent injuries. Physical examination shows tenderness and limited range of motion in the right shoulder. No signs of inflammation or effusion noted. Prescribed NSAIDs for pain management and advised physical therapy for shoulder strengthening exercises. The patient responded well to treatment and was discharged with instructions for home exercises and a follow-up appointment in two weeks. 45 Female Caucasian ICD Code: M25519

The patient has a history of occasional right elbow pain due to overuse during sports activities. The patient reports sharp pain localized to the right elbow, aggravated by movement and relieved by rest. X-ray of the right elbow shows no signs of fractures or joint effusion. Pain in right elbow. Verbatim EHR quote justifying the code: 'The patient presents with sharp pain localized to the right elbow, exacerbated by movement, consistent with a diagnosis of pain in the right elbow.' On examination, there is tenderness and mild swelling over the lateral aspect of the right elbow. No signs of inflammation or effusion noted. Prescribed rest, ice packs, and NSAIDs for pain management. Advised on elbow joint protection and gradual return to activities. Patient responded well to treatment and was discharged with instructions for home care and follow-up in two weeks. 42 Female Caucasian ICD Code: M25.521

The patient has no history of joint pain or arthritis. No previous injuries or surgeries on the left elbow. The patient reports localized pain in the left elbow exacerbated by movement and touch. No referred pain to other joints. X-ray of the left elbow shows no signs of fractures or dislocations. No effusion or swelling observed. Pain in left elbow. Verbatim_EHR_quote_justifying_the_code: 'The patient presents with localized pain in the left elbow, exacerbated by movement and touch, with no signs of referred pain or swelling to other joints.' On examination, tenderness and limited range of motion noted specifically in the left elbow joint. No warmth or redness present. Prescribed NSAIDs for pain management. Advised rest and ice application to the left elbow. Follow-up scheduled in two weeks. 45 Female Caucasian ICD Code: M25522

The patient has a history of occasional wrist pain due to repetitive use during work. The patient complains of persistent pain localized to the left wrist, exacerbated by movement and relieved by rest. X-ray of the left wrist shows no signs of fractures or dislocations, ruling out traumatic causes of pain. Pain in left wrist (M25532): Patient presents with localized pain in the left wrist, exacerbated by movement and with no signs of fractures on imaging. The patient reports no recent trauma or injury to the left wrist. Physical examination reveals tenderness and limited range of motion in the left wrist. Prescribed NSAIDs for pain management and advised wrist immobilization with a splint for a few weeks. Follow-up scheduled in two weeks for reassessment. The patient responded well to treatment with reduced pain intensity. Advised to continue NSAIDs and wear the splint as directed. 42 Female Caucasian ICD Code: M25532

The patient has a history of occasional joint pain due to overuse during work-related activities. The patient presents with sharp pain and stiffness in the joints of the right hand, especially when gripping objects. X-ray of the right hand shows no signs of fractures or dislocations, ruling out traumatic causes of pain. Pain in joints of right hand. Verbatim EHR quote justifying the code: 'The patient reports sharp pain and stiffness specifically localized in the joints of the right hand, exacerbated by gripping activities.' Physical examination reveals tenderness and limited range of motion in the right hand joints. No signs of inflammation or swelling noted. Prescribed NSAIDs for pain management and advised hand exercises to improve flexibility and reduce discomfort. The patient responded well to treatment, with decreased pain and improved hand function. Discharged with recommendations for follow-up with a rheumatologist if symptoms persist. 45 Female Caucasian ICD Code: M25541

The patient has a history of osteoarthritis in the left hand and has been experiencing recurrent pain in the joints of the left hand. The patient presents with localized pain, swelling, and stiffness specifically in the joints of the left hand. There are no symptoms reported in other joints or areas of the body. X-ray of the left hand shows mild joint space narrowing and osteophyte formation consistent with osteoarthritis in the left hand. Pain in joints of left hand (M25542): Patient presents with localized pain, swelling, and stiffness specifically in the joints of the left hand. The patient reports that the pain in the left hand joints has been persistent and is aggravated with movement. Physical examination reveals tenderness and limited range of motion in the joints of the left hand. Prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management and recommended hand exercises to improve joint flexibility. The patient was discharged with pain relief medication and advised to follow up with a rheumatologist for further management of osteoarthritis in the left hand. 67 Female Caucasian ICD Code: M25542

The patient has a history of osteoarthritis in the left hip. The patient complains of persistent pain localized in the left hip joint. X-ray of the left hip shows degenerative changes consistent with osteoarthritis. Pain in left hip (M25552): Pain in left hip The patient reports aggravation of pain with movement and relief at rest. Physical examination reveals tenderness over the left hip joint with limited range of motion. Prescribed NSAIDs for pain management and advised physical therapy for strengthening exercises. The patient was discharged in stable condition with improved pain control and advised to follow up with the orthopedic specialist for further management. 68 Female Caucasian ICD Code: M25552

The patient has a history of occasional hip discomfort exacerbated by prolonged standing or walking. The patient reports a dull, aching pain in the right hip joint, worsened by weight-bearing activities. X-ray of the right hip shows no signs of fractures or degenerative changes. Pain in unspecified hip (M25559): The patient presents with a dull, aching pain in the right hip joint, exacerbated by weight-bearing activities. On examination, tenderness is noted over the right hip joint with no signs of redness or swelling. Range of motion is slightly limited due to pain. Prescribed acetaminophen for pain management and advised on hip-strengthening exercises. Follow-up in two weeks for reevaluation. The patient was discharged with improved pain control and advised to continue with prescribed exercises. Follow-up scheduled in two weeks for further assessment. 55 Female Caucasian ICD Code: M25559

The patient has a history of occasional ankle sprains due to sports activities. The patient presents with sharp pain localized in the right ankle and joints of the right foot. The pain worsens with movement and is accompanied by mild swelling and tenderness upon palpation. X-ray of the right ankle and foot shows no fractures or dislocations, ruling out traumatic causes of pain. Pain in right ankle and joints of right foot. Verbatim EHR quote justifying the code: 'The patient presents with sharp pain localized in the right ankle and joints of the right foot. The pain worsens with movement and is accompanied by mild swelling and tenderness upon palpation.' Upon examination, there is no redness or warmth over the affected area. Range of motion of the right ankle is slightly limited due to pain. Prescribed rest, ice, compression, and elevation (RICE protocol) along with nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management. Advised the patient to avoid weight-bearing activities. The patient's pain improved with the prescribed treatment. Advised the patient to follow up if symptoms persist or worsen. 42 Female Caucasian ICD Code: M25571

The patient has a history of occasional ankle sprains during sports activities. The patient presents with sharp and persistent pain localized in the left ankle joint and the joints of the left foot, exacerbated by weight-bearing. X-ray of the left ankle and foot shows no signs of fractures or dislocations, ruling out traumatic causes of pain. Pain in left ankle and joints of left foot (M25572): The patient presents with sharp and persistent pain localized in the left ankle joint and the joints of the left foot, exacerbated by weight-bearing. X-ray ruled out traumatic causes. The patient reports no recent injuries or traumas that could explain the pain. Physical examination reveals tenderness and slight swelling around the left ankle joint. Prescribed rest, ice, elevation, and nonsteroidal anti-inflammatory drugs (NSAIDs) for pain management. Referral to a physical therapist for strengthening exercises. The patient responded well to treatment and reported decreased pain intensity. Advised on gradual return to physical activities and follow-up in two weeks for reassessment. 42 Female Caucasian ICD Code: M25572

The patient has a history of occasional ankle sprains but no significant chronic conditions related to the joints or feet. The patient complains of persistent pain in the ankle and joints of the foot, aggravated by weight-bearing activities. X-ray imaging of the ankle and foot shows no signs of fractures or dislocations, ruling out traumatic causes of pain. Pain in unspecified ankle and joints of unspecified foot. Verbatim_EHR_quote_justifying_the_code: The patient presents with persistent pain localized in the ankle and joints of the foot, exacerbated by weight-bearing activities. Physical examination reveals tenderness and mild swelling around the ankle joint, with no signs of inflammation in other joints. Range of motion in the ankle and foot is slightly limited due to pain. Prescribed NSAIDs for pain management, advised rest, ice, compression, and elevation (RICE protocol) for symptomatic relief. Referral to physical therapy for strengthening exercises. The patient responded well to treatment and reported decreased pain intensity. Discharged with instructions for home care and follow-up with the orthopedist in two weeks. 45 Female Caucasian ICD Code: M25.579

The patient has a history of moderate osteoarthritis in the left knee. The patient complains of persistent pain, stiffness, and limited range of motion in the left knee. X-ray of the left knee shows osteophytes along the joint margins. Osteophyte, left knee (M25.762): The patient presents with pain and limited range of motion in the left knee. X-ray findings reveal osteophytes along the joint margins, consistent with the diagnosis of osteophyte in the left knee. The patient reports that the symptoms have been gradually worsening over the past few months. Physical examination indicates tenderness over the affected knee joint with crepitus on movement. Prescribed NSAIDs for pain management, advised physical therapy to improve knee flexibility and strength. Patient responded well to treatment with reduced pain and improved range of motion. Discharged with instructions for home exercises and a follow-up appointment in two weeks. 65 Female Caucasian ICD Code: M25.762

The patient has a history of chronic lower back pain and stiffness. The patient presents with localized pain in the lower back that worsens with movement and improves with rest. There is no radiation of pain to the hips, knees, or other joints. X-ray of the lumbar spine shows bony outgrowths consistent with osteophytes at multiple vertebral levels. Osteophyte, vertebrae (M25.78) Physical examination reveals limited range of motion in the lumbar spine with tenderness over the affected vertebrae. Neurological examination is unremarkable. Prescribed NSAIDs for pain management, advised on posture correction, and referred to physical therapy for strengthening exercises. The patient responded well to treatment and demonstrated improved mobility. Discharged with recommendations for continued physical therapy and follow-up in two weeks. 58 Female Caucasian ICD Code: M25.78

The patient has a history of orthodontic treatment during adolescence but did not follow up for regular dental check-ups. The patient reports difficulty chewing and occasional jaw clicking. Panoramic dental x-ray shows misalignment of the teeth and jaws. Malocclusion, unspecified. The patient presents with misalignment of the teeth and jaws, as evidenced by the panoramic dental x-ray. The patient's malocclusion is likely contributing to their difficulty chewing. No signs of joint inflammation or pain in the hips, knees, or ankles were noted during the examination. Orthodontic consultation recommended for evaluation and treatment of malocclusion. The patient was discharged with a referral to an orthodontist for further management of the malocclusion. 32 Female Caucasian ICD Code: M264

The patient has a history of occasional jaw pain and discomfort while chewing over the past six months. No history of trauma or other significant medical conditions. The patient presents with bilateral jaw pain worsened by chewing, clicking sounds in the jaw joint, and occasional headaches. Limited jaw movement and tenderness around the temporomandibular joint are also reported. Physical examination reveals tenderness to palpation over the temporomandibular joint. No abnormalities noted on dental X-rays. MRI shows no structural abnormalities in the temporomandibular joint. Temporomandibular joint disorder, unspecified. Verbatim EHR quote justifying the code: 'Patient presents with bilateral jaw pain worsened by chewing, clicking sounds in the jaw joint, limited jaw movement, and tenderness around the temporomandibular joint.' The patient reports increased stress levels recently. No signs of malocclusion or dental issues observed. Advised on stress management techniques and prescribed a soft diet along with jaw exercises. Treatment includes a soft diet, jaw exercises, and over-the-counter pain relievers. Referral to a physical therapist for jaw exercises and stress management techniques. Patient responded well to treatment and reported decreased jaw pain and improved jaw movement. Discharged with instructions to continue jaw exercises and follow up in two weeks. 38 Female Caucasian ICD Code: M26.60

The patient has a history of occasional jaw pain and clicking in the jaw joint. The patient presents with jaw pain exacerbated by chewing and limited jaw movement. Physical examination reveals tenderness over the temporomandibular joint and clicking sounds during jaw movement. Unspecified temporomandibular joint disorder, unspecified side. Verbatim_EHR_quote_justifying_the_code: 'Patient presents with jaw pain exacerbated by chewing and limited jaw movement. Physical examination reveals tenderness over the temporomandibular joint and clicking sounds during jaw movement.' The patient reports no history of trauma to the jaw or recent dental procedures. No signs of malocclusion or other dental abnormalities noted. Prescribed NSAIDs for pain management and advised soft diet. Referral to a dentist for further evaluation. Patient responded well to treatment, pain reduced significantly, and advised to follow up with the dentist for ongoing management. 42 Female Caucasian ICD Code: M26609

The patient has a history of occasional jaw pain and discomfort while chewing over the past six months. The patient presents with persistent jaw pain, clicking sounds in the temporomandibular joint, and difficulty opening the mouth fully. MRI of the temporomandibular joint shows disc displacement without reduction. Other specified disorders of temporomandibular joint (M2669) The patient reports worsening jaw pain over the last month, especially while eating hard foods. Physical examination reveals tenderness over the right temporomandibular joint with crepitus on jaw movement. Prescribed NSAIDs for pain management, advised soft diet, and referred to a maxillofacial specialist for further evaluation. The patient was discharged in stable condition with improved pain control and a follow-up appointment scheduled with the specialist. 42 Female Caucasian ICD Code: M2669

The patient has a history of recurrent fevers, unintentional weight loss, and chronic muscle pain. The patient presents with skin ulcers on the lower extremities, livedo reticularis, and neuropathy symptoms like tingling and numbness in the hands and feet. Laboratory tests show elevated ESR and CRP levels indicative of systemic inflammation. Angiography reveals multiple aneurysms in visceral arteries. Polyarteritis nodosa (M300): Medium vessel vasculitis affecting multiple organs, presenting with livedo reticularis, skin ulcers, muscle pain, and neuropathy. The patient shows classic signs of medium vessel vasculitis with skin and neurological involvement. Treatment with high-dose corticosteroids and immunosuppressants has been initiated. The patient is started on prednisone and cyclophosphamide to control the vasculitis and prevent further organ damage. The patient responded well to treatment and is being discharged with a tapering regimen of prednisone and close follow-up for disease monitoring. 56 Female Caucasian ICD Code: M300

The patient has a history of asthma and sinusitis, which were previously managed by an allergist. Presented with worsening shortness of breath, cough with blood-tinged sputum, and peripheral neuropathy. High eosinophil count on complete blood count (CBC) and positive perinuclear antineutrophil cytoplasmic antibodies (p-ANCA). Chest X-ray showed bilateral pulmonary nodules. Polyarteritis with lung involvement [Churg-Strauss]. Verbatim quote: 'The patient presents with asthma, sinusitis, peripheral neuropathy, high eosinophil count, positive p-ANCA, and bilateral pulmonary nodules, consistent with Polyarteritis with lung involvement [Churg-Strauss].' The patient's symptoms and diagnostic tests are indicative of Churg-Strauss syndrome. There are no findings suggestive of other types of vasculitis or inflammatory conditions. Started on high-dose corticosteroids and immunosuppressants for the management of Polyarteritis with lung involvement. Referral to a rheumatologist for further care. The patient responded well to treatment and was discharged with a tapering regimen of corticosteroids. Follow-up with the rheumatologist in two weeks for monitoring. 47 Female Caucasian ICD Code: M301

The patient has a history of hypertension and osteoarthritis. The patient presents with severe headaches, jaw pain with chewing, stiffness in the shoulders and hips, fatigue, and unintentional weight loss. Laboratory tests show elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). A temporal artery biopsy reveals giant cells consistent with giant cell arteritis. Giant cell arteritis with polymyalgia rheumatica. Verbatim EHR quote justifying the code: The patient presents with classical symptoms of giant cell arteritis including severe headache, jaw claudication, elevated inflammatory markers, and positive temporal artery biopsy. Patient reports significant improvement in symptoms after starting glucocorticoid therapy. Started on prednisone 20mg daily for suspected giant cell arteritis. Advised on the importance of regular follow-ups and monitoring for potential side effects of long-term steroid use. The patient responded well to treatment and was discharged with a tapering regimen of prednisone. Follow-up scheduled in two weeks for clinical reassessment. 72 Female Caucasian ICD Code: M315

The patient has a history of hypertension and hyperlipidemia, both well-controlled with medications. No history of polymyalgia rheumatica, aortic arch syndrome, or other autoimmune diseases. The patient presents with severe headaches, scalp tenderness, jaw claudication, and vision changes in the right eye. No symptoms of polymyalgia rheumatica or aortic arch involvement. Elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels. Temporal artery biopsy showing giant cells. Other giant cell arteritis The patient's symptoms, elevated inflammatory markers, and positive temporal artery biopsy are consistent with a diagnosis of Other giant cell arteritis. No evidence of polymyalgia rheumatica or aortic arch involvement. Started on high-dose corticosteroids with a tapering regimen. Advised on the importance of regular follow-ups and monitoring for potential side effects of corticosteroid therapy. The patient responded well to treatment and reported a significant improvement in symptoms. Discharged home with a tapering course of corticosteroids and a follow-up appointment scheduled in two weeks. 68 Female Caucasian ICD Code: M316

The patient has a known history of systemic lupus erythematosus with previous episodes of joint pain and skin rashes. The patient presents with shortness of breath, chest pain, and a non-productive cough. Chest X-ray shows bilateral pleural effusions and ground-glass opacities. Pulmonary function tests reveal restrictive lung patterns. Lung involvement in systemic lupus erythematosus. The patient's symptoms, along with the diagnostic test results, are consistent with lung involvement in systemic lupus erythematosus. No evidence of other systemic vasculitides or granulomatous diseases. Started on high-dose corticosteroids and initiated on hydroxychloroquine for lupus management. The patient responded well to treatment and was discharged home with a tapering dose of corticosteroids. Follow-up scheduled in two weeks for reassessment. 42 Female Caucasian ICD Code: M3213

The patient has a known history of systemic lupus erythematosus with previous episodes of lupus nephritis. No history of other autoimmune diseases or vasculitis. Presented with edema in lower extremities, hypertension, and foamy urine. Denies chest pain, shortness of breath, joint pain, muscle weakness, or skin changes. Laboratory tests revealed proteinuria, hypoalbuminemia, elevated serum creatinine, and positive anti-double-stranded DNA antibodies. Renal biopsy confirmed the presence of glomerular lesions consistent with lupus nephritis. Glomerular disease in systemic lupus erythematosus (M32.14) - Systemic lupus erythematosus with nephrotic syndrome: This code is used for patients with lupus nephritis presenting with nephrotic syndrome, proteinuria, and glomerular involvement. The patient's symptoms, medical history, and diagnostic tests are consistent with glomerular disease in the setting of systemic lupus erythematosus. Renal biopsy results confirm the lupus-related glomerular pathology. Initiated on high-dose corticosteroids and mycophenolate mofetil for the management of lupus nephritis. Blood pressure control with angiotensin-converting enzyme inhibitors. Close monitoring of renal function and proteinuria. The patient responded well to treatment with improvement in proteinuria and edema. Discharged with a tapering regimen of corticosteroids and close follow-up with the rheumatology and nephrology teams. 42 Female Caucasian ICD Code: M32.14

The patient has a history of joint pain, fatigue, photosensitivity, and a positive ANA test. The patient presents with joint pain, fatigue, oral ulcers, and photosensitivity. ANA test positive, anti-dsDNA antibodies positive, low complement levels. Systemic lupus erythematosus, unspecified (M329): The patient presents with joint pain, fatigue, oral ulcers, photosensitivity, positive ANA test, positive anti-dsDNA antibodies, and low complement levels. The patient shows classic symptoms of systemic lupus erythematosus, including joint pain, fatigue, and positive serological markers. No findings suggestive of other specific organ involvement. Prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) for joint pain, hydroxychloroquine for disease modification, and sun protection measures. The patient responded well to treatment and was discharged with a follow-up appointment in one month. 37 Female Caucasian ICD Code: M329

The patient has a history of progressive muscle weakness, fatigue, and difficulty swallowing over the past few months. The patient presents with muscle weakness in the hips and shoulders, fatigue, and mild dysphagia. Creatine kinase levels are significantly elevated, electromyography shows myopathic changes, and muscle biopsy reveals inflammatory infiltrates consistent with Polymyositis. Polymyositis, organ involvement unspecified. Verbatim_EHR_quote_justifying_the_code: 'Muscle biopsy findings reveal inflammatory infiltrates consistent with Polymyositis.' The patient is experiencing progressive muscle weakness and elevated muscle enzymes, supporting the diagnosis of Polymyositis. Initiated on high-dose corticosteroids and referred to a rheumatologist for further management. The patient responded well to treatment and was discharged with a tapering dose of prednisone. Follow-up with the rheumatologist is recommended to monitor response to therapy. 54 Female Caucasian ICD Code: M3320

The patient has a history of progressive muscle weakness and skin changes over the past few months. The patient presents with symmetrical proximal muscle weakness, Gottron's papules, and heliotrope rash. Creatine kinase levels are significantly elevated, electromyography shows myopathic changes, and muscle biopsy reveals perifascicular atrophy. Dermatopolymyositis, unspecified, organ involvement unspecified. Verbatim_EHR_quote_justifying_the_code: 'The patient presents with symmetrical proximal muscle weakness, Gottron's papules, and heliotrope rash. Diagnostic tests confirm significantly elevated creatine kinase levels, myopathic changes on electromyography, and perifascicular atrophy on muscle biopsy.' The patient is experiencing muscle weakness affecting daily activities, characteristic skin changes, and elevated muscle enzymes indicative of dermatopolymyositis. Initiated on high-dose corticosteroids and referred to a rheumatologist for further management. The patient responded well to treatment with improved muscle strength and resolution of skin manifestations. Discharged with a tapering dose of corticosteroids and follow-up scheduled with the rheumatologist. 52 Female Caucasian ICD Code: M3390

The patient has a history of limited cutaneous systemic sclerosis, Raynaud's phenomenon, and esophageal dysfunction. The patient presents with skin thickening, Raynaud's phenomenon, dysphagia, and telangiectasias on the hands and face. Positive anti-centromere antibodies, abnormal nailfold capillaroscopy showing dilated capillaries and hemorrhages. CR(E)ST syndrome (M341): Limited systemic sclerosis with calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia. The patient's symptoms and diagnostic tests support the diagnosis of CR(E)ST syndrome. No evidence of other systemic autoimmune diseases or specific organ involvement outside the criteria for M341. Initiated treatment with calcium channel blockers for Raynaud's phenomenon, proton pump inhibitors for esophageal symptoms, and topical treatments for digital ulcers. The patient was discharged with a follow-up appointment in the rheumatology clinic in two weeks. 54 Female Caucasian ICD Code: M341

The patient has a history of Raynaud's phenomenon, skin thickening, and dysphagia over the past year. Presented with shortness of breath, non-productive cough, and digital ulcers. High-resolution CT scan showing interstitial lung disease with fibrosis. Pulmonary function tests indicating restrictive lung pattern. Systemic sclerosis with lung involvement (M3481): The patient presents with skin thickening, Raynaud's phenomenon, dysphagia, interstitial lung disease, and restrictive lung pattern on pulmonary function tests. The patient's symptoms and diagnostic tests are consistent with systemic sclerosis with lung involvement. No evidence of microscopic polyangiitis, lupus pericarditis, glomerular disease, or myositis. Started on immunosuppressive therapy, pulmonary rehabilitation, and proton pump inhibitors for gastroesophageal reflux. The patient responded well to treatment, with improved lung function and reduced cough. Discharged home with a follow-up appointment in three months. 54 Female Caucasian ICD Code: M3481

The patient has a history of progressive skin thickening and tightening over the past year. The patient presents with Raynaud's phenomenon, dysphagia, and shortness of breath on exertion. Pulmonary function tests show restrictive lung disease with reduced DLCO. Anti-Scl-70 antibodies are positive. Systemic sclerosis, unspecified (M349) Skin exam reveals thickening and hardening of the skin. No evidence of active synovitis or myositis. No renal involvement noted. Pulmonary auscultation reveals Velcro-like crackles at lung bases. Started on nintedanib for interstitial lung disease. Prescribed calcium channel blockers for Raynaud's phenomenon. Referral made to rheumatology for further management. Patient discharged in stable condition with close follow-up scheduled with rheumatology for ongoing management of systemic sclerosis. 55 Female Caucasian ICD Code: M349