Santa Skips Gastric Bypass, Is Discharged in Time for His December 24 Sleigh Ride

Mon, Dec 21, 2015 --

ICD-10, Skill Sharpener

Christmas Craziest ICD-10 Codes

Halloween is long gone, Thanksgiving is over, and Christmas is coming fast! What better time to share the results of the recent hospitalization of Santa Claus? Don’t worry, Santa authorized us to release his information to you, because he’s just that kind of giving, sharing guy. What follows is Santa’s actual discharge summary from Mt. McKinley Bariatric Hospital.

PATIENT NAME: CLAUS, NICHOLAS “SANTA”

DATE OF BIRTH: 12/25/0270

DATE OF ADMISSION: November 30, 2015

DATE OF DISCHARGE: December 1, 2015

CHIEF COMPLAINT: Morbid obesity.

HISTORY OF PRESENT ILLNESS: This is the first Mt. McKinley Bariatric Hospital admission for this robust, jolly, obese 1745-year-old Caucasian male who was admitted at this time for bariatric surgery. The patient is a pilot, and he states he was warned by the Federal Aviation Administration (FAA) that he could not pass his physical examination for re-licensing without undergoing some weight loss. Patient reports an annual weight gain of approximately 100 pounds each December 25.

PAST MEDICAL HISTORY: Patient reports seasonal allergies causing rhinorrhea, sneezing, coughing, and ocular pruritus. Complains of frostbite annually during what he calls “a long night of work in the cold.” Patient states he is allergic to artificial sweeteners but reports no known allergies to medications.

SOCIAL HISTORY: Smokes a pipe, drinks socially. Lives with his wife and a large number of small persons that he refers to as “elves.” He has no children of his own. He runs a sideline business breeding reindeer, and during the Christmas season he “moonlights” as a photographer’s model for department stores.

FAMILY HISTORY: Medical history of parents is unknown. He has no siblings.

REVIEW OF SYSTEMS: HEENT: Within normal limits. Skin: Reports swollen, red hands and fingers, which he attributes to driving his sleigh through a cold front over Fairbanks en route to the hospital today. Cardiorespiratory: Breath sounds normal without wheezing. GI: Morbid obesity; see history of present illness. Extremities: Patient complains of pain and coldness of his fingertips. Neuropsychiatric: Patient reports feeling mild work-related anxiety, stating that November and December are the peak times for his business.

PHYSICAL EXAMINATION: Vital signs normal. Weight 357 pounds, height 6 feet 1 inch. In general, this is a well-developed, overly well-nourished, markedly obese white male with a well-groomed flowing white beard who is in no acute distress. Skin: Redness with prominent telangiectasis appearing consistent with rosacea, with no pustules or papules present at this time. On HEENT examination, arcus senilis was present bilaterally. Nose was erythematous, cold, and displayed prominent pores, consistent with rhinophyma, otherwise unremarkable. Lungs clear, heart regular rate and rhythm. Abdomen soft, obese, round, shakes like a bowl full of jelly. Genitalia and rectal: Patient refused this examination; cannot rule out bilateral gluteal frostbite. Extremities: Fingertips are erythematous and cold, consistent with frostnip. Neurologic: Cranial nerves II through XII were intact.

HOSPITAL COURSE: The patient was admitted to undergo laparoscopic Roux-en-Y gastric bypass for morbid obesity. However, following admission, the phlebotomist noted an inability to attain hemostasis after the patient underwent a blood draw for preoperative diagnostic studies. Hematology was consulted, who evaluated the patient for bleeding disorders. Patient underwent workup including hemoglobin and hematocrit, which were low normal, with a normal platelet count. However, Factor IX (FIX) assay was undertaken and was positive for Christmas disease. The patient reported that he has tended to easy bruising and bleeding since childhood, but that he felt the condition was normal for him. We discussed beginning him on Rixubis prophylaxis for his Christmas disease, but he declined this therapy, saying that he had survived just fine for 1745 years without medication and didn’t see a reason to start it now.

Given his new diagnosis of hemophilia B, Bariatric Surgery cancelled his Roux-en-Y procedure. The patient agreed to join Weight Watchers and start an exercise program on January 2 to lose the 100 pounds he expects to pack on while eating cookies and drinking egg nog as he travels around the planet on Christmas Eve.

DISCHARGE DIAGNOSES:

  1. Christmas disease, newly diagnosed.
    D67, Hereditary factor IX deficiency (Christmas disease).
  2. Morbid obesity.
    E66.01, Morbid (severe) obesity due to excess calories.
  3. Early frostbite of upper extremities, resolved.
    T33.53XA, Superficial frostbite of finger(s).
  4. Exposure to excessive cold.
    X31.XXA, Exposure to excessive natural cold, initial encounter
  5. Facial rosacea with rhinophyma.
    L71.1, Rhinophyma.

OPERATIONS: None.

CONSULTATIONS: Mark U. Bloodborne, MD, Hematology.

DISPOSITION: Diet: 1500-calorie ADA diet for weight loss. Medications: None. Patient was counseled on the need to stop smoking, and he said he would consider use of nicotine patches as an outpatient. Patient was counseled on the importance of a healthy weight-loss diet and exercise program, which he agreed to pursue as an outpatient. Patient refused medical treatment for his Christmas disease at this time. He will follow up with Dr. Bloodborne in 4 weeks. He is released to return to work without restrictions.

Leslie A. Lipozene, MD
D-T: 12/1/2015
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About 

Susan taught health information and healthcare documentation at the community college level for more than 20 years. She has a special love for medical language and terminology. She is passionate about ensuring accurate patient healthcare documentation through education. She has a master's degree in healthcare administration, is a certified healthcare documentation specialist, and serves as immediate past president for the Association for Healthcare Documentation Integrity (AHDI).

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4 Comments For This Post

  1. Jody Gall, RHDS Says:

    Susan, I loved this. I hope you don’t mind, but I printed it to share around my workplace.

  2. Jody Gall, RHDS Says:

    OH, goodness, I forgot to mention that I gave credit where credit is due, including your bio at the top of the page.

  3. Susan Dooley Says:

    Jody, I’m thrilled that you liked it enough to share with your coworkers! My colleagues at a Gainesville hospital and I created an H&P for Santa way back in the ’80s, and we posted it on the department door as part of our holiday decor. That H&P was the seed for this discharge summary. Thanks for sharing, and keep coming back! 🙂

  4. Susan Dooley Says:

    Hey, Dr. Parr, thanks for the shoutout! And happy new year to you. Susan

1 Trackbacks For This Post

  1. Dr. Brian Parr Says:

    I saw this report on Santa’s health. This is a rare look at a page from Santa’s medical records and an […]

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