Question: PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way . SOMEWHERE, FL 32811. 407-555-6789 PATIENT: LOPEZ, JUANA ACCOUNT/EHR #: LOPEJU001 DATE: 07/16/21 Attending Physician: Oscar R. Prader, MD S: Patient Is A 15-year-old Female With Complaints Of Dysphagia And Occasional Problems Speaking. She Complains Of Dyspnea And Finds …

PRADER, BRACKER, & ASSOCIATES A Complete Health Care Facility 159 Healthcare Way . SOMEWHERE, FL 32811. 407-555-6789 PATIENT: LOPEZ, JUANA ACCOUNT/EHR #: LOPEJU001 DATE: 07/16/21 Attending Physician: Oscar R. Prader, MD S: Patient is a 15-year-old female with complaints of dysphagia and occasional problems speaking. She complains of dyspnea and finds it painful to raise her arms over her head. In the last couple of days, she states that climbing stairs and even getting up from a chair are painful and challenging. O: ROM indicates weakness in the proximal muscles, specifically shoulders and hips. Both MRI and electromyography indicate polymyositis with myopathy. This was confirmed by autoimmune antibody testing, A: Polymyositis with myopathy P: Rx: Prednisone Rx: Methotrexate Using the techniques described in this chapter carefully read through the case study and determine the most accurate ICD-10-CM code(s) and external cause code(s) if appropriate. Remember, check the chapter specific, sub-chapter specific and category specific notations within the Tabular list.