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© Irene Mueller EdD, RHIA May 16, 2013.  Review Common Brain Pathologies for ICD-10- CM/PCS Coding  Circulatory pathologies affecting brain  Neurological.

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Presentation on theme: "© Irene Mueller EdD, RHIA May 16, 2013.  Review Common Brain Pathologies for ICD-10- CM/PCS Coding  Circulatory pathologies affecting brain  Neurological."— Presentation transcript:

1 © Irene Mueller EdD, RHIA May 16, 2013

2  Review Common Brain Pathologies for ICD-10- CM/PCS Coding  Circulatory pathologies affecting brain  Neurological pathologies affecting brain  ICD-10-CM/PCS Terminology (Integrated) Did you Complete the PRE-Test?

3  Circulatory pathologies affecting brain  Neurological pathologies affecting brain

4  Affect Cerebral & Precerebral blood vessels  Atherosclerosis  Aneurysm  Stroke  Non-traumatic hemorrhage  Infarction/obstruction  Occlusion/Stenosis

5  Build up of waxy plaque on inside of blood vessels (inner layer only), can block blood flow  Gk, athere = gruel, skleros = hard Atherosclerosis  Type of arteriosclerosis  Arteriosclerosis = general term for hardening of arteries (inner/middle layers of artery wall)  Arteriosclerosis can occur in several forms, including atherosclerosis  Plaque composed of fatty substances, cholesterol, waste products from cells, calcium, and fibrin

6  Inner artery wall thickens,  Artery's diameter reduced,  Blood flow and oxygen delivery are decreased (stenosis, stricture)  Plaques can rupture or crack open  Sudden formation of blood clot (thrombus, embolus)  Complete blockage  Stroke if located in precerebral/cerebral arteries

7  Response to endothelial damage  High cholesterol, High blood pressure, & cigarette smoking  All 3 = 8X more likely  Physical inactivity, diabetes, & obesity  High levels of  Homocysteine  Lipoproteins  Low levels of HDL  Heredity  Parents have AD, atherosclerosis, or stroke early  African-Americans (HTN)  Sex – Males 45+, Women 55+  Equal risk after 60

8  Localized, blood-filled dilation of blood vessel caused by disease/weakening of vessel wall  Often incidental finding  Berry aneurysm  small (size of berry) saccular aneurysm of cerebral artery, usu. at junction of vessels in Circle of Willis  Narrow opening into artery topics/topics/arm/printall-index.html

9  3 to 5 million people in US have cerebral aneurysms  Most do NOT produce symptoms  % of people may suffer from bleeding  Usually develop at arteries’ branching points  Caused by constant pressure from blood flow  Often enlarge slowly/become weaker  One aneurysm = 15 to 20 % chance of more aneurysms

10  Subarachnoid hemorrhage due to rupture of cerebral aneurysm - most common ages 20 to 60  Slightly more common in women than men  Precipitators of aneurysm rupture  Heavy lifting/straining can cause pressure to rise in brain  Strong emotions (upset/angry) can raise blood pressure  Blood “thinners” (warfarin, etc.)  Some meds/prescription drugs (also stimulant diet pills such as ephedrine and amphetamines)  Harmful drugs like cocaine can cause aneurysms to rupture and bleed

11  Other blood vessel disorders  Fibromuscular dysplasia, cerebral arteritis or arterial dissection  VERY unusual  Infections  Drugs (amphetamines/cocaine) that damage brain blood vessels  Direct brain trauma from accident  Elderly = Falls  Young = MVAs

12  Size  Small = < 5 mm (1/4 inch)  Medium = 6–15 mm (1/4 to 3/4 inch)  Large = 16–25 mm (3/4 to 1 inch)  Giant = > 25 mm (1 inch+)  Shape  Saccular (sack-like) with a well-defined neck  Saccular with wide neck  Fusiform (spindle shaped) without a distinct neck  Location  Cerebral aneurysm –usu. located along major arteries deep within brain structures  Anterior OR posterior circulation

13  AKA - Brain attack, CVA, CVI (Cerebrovascular Insult), Infarct, Apoplexy  Sudden death of brain cells in localized area due to inadequate blood flow  Single most costly disease  3.4 million women in the US living  w/disabilities resulting from stroke

14  Lifestyle  Tobacco Use & Smoking  Alcohol Use  Physical Inactivity  Obesity  Medical  High Blood Pressure  Atrial Fibrillation  High Cholesterol  Diabetes  Atherosclerosis/Circulation Problems  Migraine  esp. women <55  Sickle Cell Disease  Sleep Apnea  TIA

15  55 +  Male (Female in later years)  African American, Hispanic or Asian/Pacific Islander  Family Hx of stroke or TIA  Fibromuscular Dysplasia  PFO (congenital heart defect)  Low birth weight  Study showed weight < 5 lb., 8 oz. at birth = 2X stroke risk as weight of 8 lb., 13 oz +



18  SUDDEN (Men & Women)  Numbness/weakness of face, arm or leg – especially one side of body  Confusion, trouble speaking or understanding  Trouble seeing in one or both eyes  Trouble walking, dizziness, loss of balance or coordination  Severe headache w/no known cause  Women may report unique stroke symptoms  SUDDEN  Face and limb pain  General weakness  Palpitations  Chest pain  Hiccups  Nausea  SOB

19  Common stroke symptoms  Loss of balance or coordination  Dizziness (Vertigo – spinning sensation)  Slurred speech (Dysphasia)  Loss of previous ability to speak/understand spoken or written language (Aphasia) NOT Aphagia  Dysphagia/Aphagia (poor, NO swallowing)  Paralysis, numbness, or weakness on one side of the body (Hemiparesis, Hemiplegia)  Blurred, double, or blackened vision (Diplopia)  Sudden, severe headache (Cephalalgia, encephalgia)

20 30-Day Death Rates for Different Types of Stroke Ischemic Stroke Hemorrhagic Stroke Women7%30% Men8%35% 45 to 64 y-o8% to 12%37% 65 y-o +8%45%

21 PT Sex/Age w/i1 yrw/I 5 yrs Female DEATH (40+) 24%51% Male DEATH21%47% Female 2 nd Stroke22% Male 2 nd Stroke13% Female (60-69) AVG Survival7.4 years Male (60-69) AVG Survival6.8 years Female (80+)3.1 years Male (80+)1.8 years

22  50% to 70% of stroke survivors eventually regain functional independence  15% to 30% permanently disabled  65 +y-o survivors of ischemic stroke had disabilities 6 mos. post-stroke  50% hemplegia  35% depressive symptoms  30% couldn’t walk w/o assistance  26% in nursing home  26% dependent in ADLs  19% aphasia

23  Ischemic (80 +%)  Thrombus (Clot)  Embolus (MOVING Clot)  Occlusion  Stenosis  Hemorrhagic (More Severe)  Blood vessel in brain leaks or ruptures  Common types include  Intracerebral  Subarachnoid  Extradural/epidural  Subdural hemorrhages topics/topics/stroke/printall-index.html

24  AKA – Hemorrhagic Stroke  Subarachnoid  Outside brain  Between Arachnoid and Pia mater  Intracerebral  Within brain  Causes  Intracranial aneurysm (most common)  AV malformation, Tumor, Infection

25  AKA – Ischemic stroke  Blood supply to brain site is interrupted or severely reduced  Brain tissue is starved of O 2 and nutrition  Ischemia Necrosis  Causes  Thrombus or embolus blocks blood flow in cerebral OR precerebral arteries

26  Occlusion L, occludere, to close up  blockage in a canal, vessel, or passage of body; state of being closed  AKA – obstruction of precerebral/cerebral arteries  Stenosis [Gr.] stricture;  AKA - arctation, coarctation, stricture  Abnormal narrowing or contraction of duct or canal  Narrowing of artery can decrease blood supply to brain  Increases risk of CVA

27  Has blood supply loss caused DEATH of brain cells/tissue?  Evidence of Death of brain cells =  Speech/language deficits  Monoplegia  Hemiplegia  Other cognitive or functional deficits  Occlusion w/ or w/o cerebral infarction  Classified separately based on IF infarct results from occlusion

28  Symptoms similar, BUT TIA symptoms usually resolve w/in 24 hours  AKA Little/Mini stroke – Most common cause is embolus  Precursor to Stroke in many cases  Signs/Symptoms include:  Numbness/weakness in face, extremity - usu one side  Confusion; Difficulty walking  Difficulty speaking OR understanding  Vision change in one/both eyes  Dizziness; Loss of balance/coordination  RIND - Reversible Ischemic  Neurologic Deficit  CVA/w deficits such as hemiplegia, dysphagia, slurred speech lasting longer than TIA  May persist for as long as six months  BUT eventually resolve

29  Sequela/Sequelae are residual effects or conditions produced after acute phase of illnes/injury has ended  NO time limit on when sequela code can be assigned  Residuals may be apparent early on such as in cerebral infarction, or they can occur months or years later  Cerebrovascular disease sequelae  Include aphasia, dysphagia, monoplegia, or hemiparesis  Arise from any condition classifiable to categories I60-I67  Sequalae ICD-10-CM codes REQUIRE type of Cerebrovascular Disease (has unspecified option)

30  Memory Loss  Ability to remember names/faces/shapes can be compromised  Difficulty learning new information or skill  Difficulty organizing thoughts/perform sequential tasks (Frontal lobe)  Agnosia - Inability to recognize specific familiar object, (e.g., own body hand, face, shape, or sound)  Ex: "finger agnosia" due to stroke in dominant language parietal lobe, pt can easily recognize/name car or TV, but not own thumb  Agraphia - Loss of writing ability resulting from damage to language areas of brain  After stroke often incomplete, many stroke survivors can rapidly re-learn to write some words/sentences

31  Alexia - injury prevents people from being able to read, but not to write  AKA: word blindness, pure word blindness, text blindness, or visual aphasia  Agraphia - Loss of writing ability resulting from damage to language areas of brain  After stroke, agraphia often incomplete  Many stroke survivors rapidly re-learn to write some words/sentences

32  Apraxia  Ataxia  Dystonia  Weakness or paralysis on side of body opposite stroke  Unmasking of primitive reflexes (instinctive sucking, grasping, & groping  Compulsive mimicking of facial gestures made by others  Compulsive repetition of movement (motor perseveration)

33  Distribution of weakness = Important clue to location of nerve damage  "-plegia," = Gk, - "stroke"  Classified by region  Monoplegia - only one limb  Diplegia - same body region on both sides of body (both arms, for example, or both sides of face)  Hemiplegia - one side of body  Paraplegia - both legs and trunk  Quadriplegia (Tetra-) - all four limbs and trunk

34  Right-hand patient = right-side dominant  Left-handed patient = left-hand dominant  When affected side is documented, but NOT specified as dominant/non-dominant AND classification system does not indicate default  Code selection  For ambidextrous patients, default = dominant  Left side affected, default = non-dominant  Right side affected, default = dominant

35  Pt admitted for outpatient PT therapy for monoplegia of left leg affecting non-dominant side due to spontaneous subarachnoid hemorrhage 2 weeks ago I69.044, Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side

36  A patient presents for follow-up 1 month after suffering cerebral infarction  Dr. notes pt suffers from right-sided hemiplegia due to infarction & recommends continued PT and OT I Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side

37  Pt presents w/new R middle cerebral artery embolism & infarction causing aphasia  Pt suffered ruptured cerebral aneurysm one year prior w/residual oral phase dysphagia  I Cerebral infarction due to embolism of right middle cerebral artery  *I Aphasia following cerebral infarction  I Dysphagia following nontraumatic subarachnoid hemorrhage  R13.11 Dysphagia, oral phase  *Sequalae = neurologic deficits that persist after initial onset of conditions

38  65-yo female seen for Tx of unstable angina. She has Hx of 2-vessel CABG about 18 months ago. Recent cardiac catheterization shows continued evidence of coronary atherosclerosis, but grafts are patent. Also, pt suffered CV Infarction 3 yrs ago, which resulted in R-sided (dominant) hemiparesis I Angina (attack) (cardiac) (chest) (heart) (pectoris) (syndrome) (vasomotor), with atherosclerotic heart disease – see Arteriosclerosis, coronary (artery), native vessel with angina pectoris, unstable I Hemiparesis – see Hemiplegia, following, cerebrovascular disease, cerebral infarction Z95.1 Status (post), aortocoronary bypass

39  I69.35 Hemiplegia and hemiparesis following cerebral infarction  I Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side  I Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side  I Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side  I Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side  I69.359Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side

40  Strokes in sensory cortex of parietal lobe can cause profound numbness  Astereognosis = inability to identify object by sense of touch  AKA tactile agnosia

41  Alogia - Complete lack of speech  Aphonia - Complete speechlessness resulting from inability to produce normal sounds due to organic (–eg, laryngeal disease or mental cause)  Dysphonia - Any disorder of phonation affecting voice quality/ability to produce voice  Apraxia: Inability to execute voluntary motor movement despite being able to demonstrate normal muscle function  NOT lack of understanding or physical paralysis  Problem in brain cortex

42  Aphasia - condition characterized by partial or total loss of ability to communicate verbally/written words  Pt may have difficulty speaking, reading, writing, recognizing names of objects, or understanding what other people say  Caused by brain injury  Traumatic injury  Oxygen deprivation during stroke  Brain tumor  Alzheimer  Infection, like encephalitis  Temporary or permanent  Does NOT include speech impediments caused by loss of muscle control  Dysphasia - partial or complete impairment of the ability to communicate resulting from brain injury - used more in Europe

43 Gentleman seen in clinic for followup of previous stroke. He had cerebrovascular infarction 6 months ago, which left him with aphasia and left- sided hemiparesis on his non-dominant side. Pt is referred to Outpt Rehab for ST, PT, and OT. I69.354Hemiparesis – see Hemiplegia, following, cerebrovascular disease, stroke I69.320Aphasia, following cerebrovascular disease, cerebral infarction

44  Aphagia -condition characterized by loss of ability to swallow  Result of organic disease or psychologic causes such as cerebrovascular accident or anxiety  Dysphagia - difficulty in swallowing  Numerous underlying causes  Stroke/other neurologic conditions  Local trauma and muscle damage  Tumor/swelling partially obstructing passage of food  Ranges from mild discomfort, such as feeling a lump in throat, to severe inability to control muscles needed for chewing and swallowing

45 Acute CV Infarction due to embolism of left cerebellar artery with dysphagia and right hemiplegia. I Infarct, infarction, cerebellar – see Infarct, cerebral. (See also Occlusion, artery, cerebral, or precerebral, with infarction). Occlusion, occluded artery, cerebellar (anterior inferior) (posterior inferior) (superior) with infarction, due to, embolism R13.10 Dysphagia G81.91 Hemiplegia

46  I63 Cerebral infarction  Includes: occlusion and stenosis of cerebral and precerebral arteries, resulting in cerebral infarction  Use additional code, if applicable, to identify status post administration of tPA (rtPA) in different facility within last 24 hours prior to admission to current facility (Z92.82)  Excludes1 sequelae of cerebral infarction (I69.3-)

47  I63.4 Cerebral infarction due to embolism of cerebral arteries  I63.44 Cerebral infarction due to embolism of cerebellar artery  I Cerebral infarction due to embolism of right cerebellar artery  I Cerebral infarction due to embolism of left cerebellar artery  I Cerebral infarction due to embolism of unspecified cerebellar artery  I Dysphagia following cerebral infarction  Use additional code to identify the type of dysphagia, if known (R13.1-) 47

48  R13.1 Dysphagia  Code first, if applicable, dysphagia following cerebrovascular disease (I69. with final characters -91)  Excludes1: psychogenic dysphagia (F45.8)  R13.19 Other dysphagia  Cervical dysphagia  Neurogenic dysphagia

49  Motor  Weakness or paralysis on side of body opposite stroke  Unmasking of primitive reflexes (instinctive sucking, grasping, & groping  Compulsive mimicking of facial gestures made by others  Compulsive repetition of movement (motor perseveration)  Abulia - Lack of motivation/desire to perform task  In stroke, most often due to damage to frontal lobe  Ex:s. Stroke survivor fails to move arm/leg, even though part of brain required to carry out movement is intact  Apraxia of gait  Urinary incontinence

50  Cognition and Intellect  Lack of initiative, vacillation, mood changes & inattentiveness  Difficulty solving problems (goal-directed behavior) in different areas of cognition including psycholinguistic, constructive, logical, and arithmetical  Behavior and Personality  Profound lack of initiative and motivation  Spontaneous expression of socially inappropriate remarks  Irritability  Carelessness and apathy  Inappropriate & seemingly random persistence & repetition of certain behaviors

51  Speech and Language  Broca aphasia - stroke affects dominant language hemisphere

52  Broca’s Aphasia – AKA, Motor Aphasia  Production of language is affected, (speaking) But other aspects of language are mostly preserved  Usu. prevents forming own intelligible words/sentences, but still ability to understand others. Some aphasics can say few words - telegraphic speech  Often w/other impairments –hemiparesis/hemiplegia on R side of body, alexia and agraphia  Wernicke’s Aphasia  Pts can’t understand others’, or even their own speech  Speech is incomprehensible, but pt feels being understood. (Anosagnosia)  Ex: “My door sat through the lamp in the sky.” (Logorrhea)  With time, Wernicke’s aphasics may know others can’t understand them - might become angry, paranoid, & depressed  Global Aphasia  Involves both areas  Pts can’t understand spoken language or speak  Some pts can still communicate by using written language

53  Visual Symptoms  Homonimous quadrantanopsia  AKA quadrantanopsia; quadrantic anopsia; quadrantic hemianopia  Nerve fibers carry information from lower parts of visual field  Travel through parietal lobes to occipital lobe  When damaged by parietal strokes causes vision in lower quarter of side opposite stroke to be lost  Spatial Dysperception  Difficulty interpreting visual information in surroundings, such as length, depth, & size of objects  Hand-Eye Incoordination  Difficulty bringing hand to spot where looking  EX: Pt looks at coffee mug on table, means to pick it up, but hand overshoots, and can’t grab mug.  Inability to visually scan surroundings  Has full eye movement, but prevents seeing objects, people, and other visual stimuli presented in peripheral vision

54  Abnormalities of Self-Perception  Hemineglect: parietal strokes in non-dominant language side of brain tendency to completely ignore opposite side of body  Ex: Hemiplegia due to stroke affecting both motor& sensory cortices  Pts ignore fact that one side of body completely paralyzed, but also can't recognize own body parts on that side  So fail to shave or wear lipstick on side affected by stroke  Finger agnosia  Selective inability to name fingers  Right-left confusion  Profound inability to differentiate R from L  Difficulty w/reading, writing, and math

55  Sensory Symptoms  Sensory loss  Strokes in sensory cortex (in parietal lobe) can cause profound numbness  Astereognosis  Other  Inattentiveness  Apathy  Dullness

56  Constructional apraxia  Inability to build whole from its single parts  Ex: inability to assemble simple 4-piece puzzle  Eye-opening apraxia  Inability to open eye despite will and physical ability  Ideomotor apraxia  Inability to mimic learned motor task/behavior (combing hair) Pt is unable to pantomime how to comb Results from damage to dominant-side parietal lobe

57  Language  Wernicke aphasia  Word-finding difficulties  Pure word deafness  Can’t hear words, but can recognize bells, buzzers, etc.  Can’t write when asked, but can write spontaneously  Transcortical aphasia  Uncommon  Amnestic dysnomia  Difficulty retrieving names for things/people

58  Hearing  Hearing loss  Mild when one temporal lobe affected  Complete deafness possible when both affected, but very rare  Auditory agnosia  Difficulty recognizing combinations of sounds such as songs, musical tones, and complex conversations  Auditory verbal agnosia = pure word deafness  Auditory illusion  Aberrant perception of normal sounds - feel unusual, strange, repeated, or loud  Auditory hallucinations  Hearing sounds NOT there  Complex = sound of song on radio  Simple = whistles or siren  May occur w/visual hallucinations  Pts may/may not realize these are hallucinations

59  Memory, Emotion and Behavior  Loss of short or long term memory  Fits of rage  Violent/aggressive behavior  Placidity  Lack of interest  Abnormally enhanced sexuality  Other  Vertigo (type of balance problem)  Abnormal perception of time  Feelng that time stands still /goes extremely quickly  Intermittent loss of sense of year, season or month  Disturbances of smell and taste  Seizures

60  Stroke Affecting Entire Occipital Lobe on One Side  Homonomous Hemianopia – Pt not able to see objects on opposite side of body  Stroke Affecting Occipital Pole – 'Central Vision Defect‘  Central Vision = Seen at center of visual field when looking straight ahead  Large blind spot in middle of visual field on affected side  Pt looking straight ahead at someone’s face  May not be able to see nose, upper lip, & lower half of eye on affected side  But could see shoulder and top of head on that side

61  Stroke Affecting Occipital Lobes on Both Sides – 'Cortical Blindness‘  Blindness  Also sometimes also suffer from visual anosagnosia  AKA Anton syndrome  Other  Visual Illusions - Distortion of movement, form, size or color in visual field  Visual Hallucinations  Visual Agnosias  Balint Syndrome  Prosopagnosia - Inability to recognize identity of familiar faces  Alexia W/O Agraphia

62 sa%29-3_new.jpg

63  Group of 3 symptoms occurring together  Result of stroke at border of parietal and occipital lobes  Inability to voluntarily look around in space  Inability to grab object while looking at object, due to dis-coordination of eye/hand movements  Tendency to only see one object in visual field at one time

64  Difficulty w/ coordination & posture, as well as ability to execute fluid movement  Common effects of cerebellar strokes include  Inability to walk, problems with coordination and balance (ataxia)  Dizziness  Headache  Nausea  Vomiting

65  Common effects of stroke in brain stem include problems with  Breathing and heart functions  Body temperature control  Balance and coordination  Weakness or paralysis in all four limbs  Chewing, swallowing, and speaking  Vision  Coma  Death is common

66  Acute cerebral infarction, thrombosis of left anterior cerebral artery with residual right-sided hemiplegia I Infarct, infarction, cerebral – (see also Occlusion, artery, cerebral or precerebral, with infarction). Occlusion, artery, cerebral, anterior, with infarction, due to, thrombosis OR Infarct, infarction, cerebral, due to thrombosis, cerebral artery. G81.91 Hemiplegia

67  G89.9 Hemiplegia, unspecified  G89.90 Hemiplegia, unspecified affecting unspecified side  G Hemiplegia, unspecified affecting right dominant side  G Hemiplegia, unspecified affecting left dominant side  G Hemiplegia, unspecified affecting right nondominant side  G Hemiplegia, unspecified affecting left nondominant side


69  Parkinson’s disease  Neurons producing dopamine die in basal ganglia  Causes difficulty initiating movement  Huntington’s disease  Genetic mutation causes over-production of glutamate  Kills neurons in basal ganglia  Uncontrollable twisting/writhing

70  Alzheimer’s disease –  Unusual proteins build up in & around neurons in neocortex & hippocampus  Control memory, causing inability to remember or do everyday tasks  Blows to brain or stroke damage  Can kill neurons outright OR slowly starve of oxygen and nutrients  Spinal cord injury  Can disrupt communication between brain & muscles  Neurons lose connection to axons located below site of injury; which may still live, but lose ability to communicate


72  Inflammation of encephalon (part of nervous system within cranium (brain))  Usually viral  West Nile encephalitis  Severe form of infection  Neuroinvasive affecting brain  20 % mild/moderate signs/symptoms  <1 % encephalitis/meningitis/poliomyelitis  Headache, high fever, stiff neck, stupor, coma, paralysis

73  Varicella Virus  Chicken Pox, can cause Herpes Zoster (Shingles)  Virus lies dormant in nerve cells  Reactivated = burning, itching, tingling, sensitive skin, then rash and blisters (usually one area on one side of body - dermatomes)  Herpes zoster encephalitis  Herpes zoster meningitis

74  Inflammation of membranes covering brain & spinal cord  Usu/ dura mater and/or arachnoid  AKA arachnoiditis  AKA pachymeningitis  Bacterial, Viral, Non-infectious  Acute or Chronic

75 Pt admitted with high fever, stiff neck, chest pain, and nausea. Lumbar puncture results were positive for meningitis. Chest X-ray showed pneumonia. Sputum culture grew pneumococcus. Pt tx with antibiotics. Dx: Pneumococcal meningitis and pneumococcal pneumonia. G00.1 Meningitis, pneumococcal J13 Pneumonia, pneumococcal, (broncho) (lobar)

76  G00 Bacterial meningitis, NEC  Includes : bacterial arachnoiditis  bacterial leptomeningitis  bacterial meningitis  bacterial pachymeningitis  Excludes1: bacterial: meningoencephalitis (G04.2) meningomyelitis (G04.2)  G00.0 Hemophilus meningitis  Meningitis due to Hemophilus influenzae  G00.1 Pneumococcal meningitis  Pneumonia (acute) (double) (migratory) (purulent) (septic) (unresolved) J18.9  -- pneumococcus J13  J13 Pneumonia due to Streptococcus pneumoniae  Bronchopneumonia due to S. pneumoniae  Code first: associated influenza, if applicable (J09.X1, J10.0-, -J11.0-)  Code also: associated abscess, if applicable (J85.1)  Excludes1:  congenital pneumonia due to S. pneumoniae (P23.6)  lobar pneumonia, unspecified organism (J18.1)


78  Motor neuron diseases  Affect Muscle control/strength  Many have Hereditary component

79  Atrophy  Progressive, acquired decrease in size of normally developed cell, tissue, or organ  May result from decrease in cell size, # of cells, or both  L, atrophia, Grk, from atrophos ill-fed  Ataxia  Loss of ability to coordinate muscular movement, most frequently resulting from disorders in brain/spinal cord  AKA Dyssynergia, Incoordination  Palsy  Complete or partial muscle paralysis, often accompanied by loss of sensation & uncontrollable body movements or tremors  Sclerosis  Condition characterized by hardening of tissue resulting from any of several causes  AKA Induration

80  Decrease in size and wasting of muscle tissue  Muscles that lose their nerve supply can atrophy; simply waste away lus/ency/imagepages/9680.htm

81  Disease of motor neurons  Upper Motor Neurons - Nerve cells reaching from brain to spinal cord  Spasms & tonic limbs  Abnormal reflexes  Lower Motor Neurons –from spinal cord to peripheral nerves that control muscle movement  Muscle wasting  Fasciculations (Twitching)  AKA - Lou Gerhrig’s Disease, motor neuron disease  Cause Unknown  Prognosis –  50% of pts die w/in 3 years  80% die w/in 5 years  10 % Live more than 8 years File:Gehrig_cropped.jpg

82  Hereditary spastic paraplegia (HSP) - group of inherited disorders characterized by progressive weakness & spasticity (stiffness) of legs  AKA familial spastic paraparesis (FSP)  20 genes responsible for several forms of HSP now identified  Variable prosnoses  Uncomplicated, Complicated

83  Inherited degenerative disorder of cerebral cortex & corpus striatum  AKA Huntington Chorea, hereditary chorea, chronic progressive chorea; degenerative chorea; degenerative chorea; Huntington disease, Woody Guthrie's disease  George, U.S. physician, described in 1872  HD gene located on short arm of chromosome 4  Dominant gene  Affects males and female  Can be inherited from either parent (also w/HD).  50% chance of passing it to each Child  Begins usu. in 30s-50s

84  3 categories  Motor or movement symptoms  Dystonia  Sustained abnormal postures, including facial grimaces, twisted neck, or arched back  Chorea  Involuntary jerking, twisting or writhing motions  Slowness of voluntary movements  Can’t control speed or force of movements  Can’t initiate movement  Slowed reactions  Difficulty speaking and swallowing  Localized/generalized weakness  Impaired balance ability  Rigidity, especially in late-stage disease

85  Personality and behavioral changes  Depression, irritability, anxiety and apathy  May become impulsive, aggressive or socially withdrawn  Cognitive decline  Loss of ability to plan and execute routine tasks  Slowed thought  Impaired or inappropriate judgment. Short-term memory loss usually occurs, although long-term memory is usually not affected  Pt w/ late-stage HD  Usu. retains knowledge of environment  Recognizes family members or other loved ones


87  Parkinsonism = clinical definition of variety of different underlying pathologies causing Parkinson’s-like symptoms - slowing of movement, tremor, rigidity/stiffness, & balance problems  Several disorders produce symptoms referred to as Parkinsonisms - Parkinson disease is ONLY ONE  Typical Parkinson patient has Lewy bodies in brain neurons  When patient given dopamine replacement therapy (e.g., Sinemet), symptoms go away  Parkinsonisms (AKA atypical Parkinson) – add’l symptoms do NOT respond to dopamine replacement therapy

88  James Parkinson, English physician and paleontologist (1817)  AKA - Parkinson's, idiopathic parkinsonism, primary parkinsonism, PD, hypokinetic rigid syndrome/HRS, or paralysis agitans  "Involuntary tremolous motion, with lessened muscular power, in parts not in action and even when supported; with a propensity to bend trunk forewards, and to pass from a walking to a running pace: senses and intellect being uninjured."

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90  Tremor – Resting, Pill-Rolling  Slowed movement (Bradykinesia)  Over time, reduced ability to move/slow movement  Steps may become shorter, difficult to get out of chair, shuffling walk  Rigid muscle - any body part, limiting ROM & causing pain  Impaired posture and balance  Posture may become stooped, may have balance problems  Loss of automatic movements  Decreased ability to perform unconscious movements, including blinking, smiling or swinging arms when walking, may no longer gesture when talking  Speech changes - may speak softly, quickly, slur or hesitate before talking, more monotonous, less inflections  Writing changes - may appear small and become difficult

91  Primary (75%)  Idiopathic Parkinson's disease  No cause determined  RARE Causes of 2ndary  Metabolic  Hypoparathyroidism w/ basal ganglia calcification  Hypo/Hyperthyroidism  Miscellaneous  Repeat trauma  (notably from boxing)  Structural lesions  Tumors  Infarctions  Hydrocephalus  Secondary (25%)  Vascular disease  Infectious and postinfectious  Postencephalitic – Neurosyphilis - AIDS  Toxins  ManganeseCyanide  MethanolCarbon monoxide  1-methyl-4-phenyl-1,2,3,6- tetrahydropyridine (MPTP)  Pesticides  Medications  NeurolepticsMetoclopramide  Dopamine-depleting agents (reserpine)  MethyldopaLithium  Calcium-channel blockers  Valproic acidFluoxetine

92  Parkinson pts also face 'freezing'  Feet freeze in place, but rest of body keeps moving, causing a fall – Some pts tend to become sedentary, reluctant to move, and reclusive  Parkinson's helper dogs are trained to identify when person with Parkinson's is 'freezing'  If dog touches pt’s foot, it breaks freeze and pt can continue walking  Medical experts do not know why this works  Dogs are taught to prevent pts falling by counterbalancing & helping regain footing  IF pt does fall, dog can help the person up

93  Pt taking Haloperidol as prescribed for paranoid schizophrenia. Seen for change in facial expressions and stiffness in arms and legs.  Dx: 2ndary Parkinsonism due to Haloperidol. G21.11Parkinsonism (idiopathic) (primary), secondary, due to drugs, neuroleptic T43.4X5ARefer to Drug and Chemical Table, Haloperidol, adverse effect F20.0Schizophrenia, paranoid (type)

94  G21 Secondary parkinsonism  Excludes1:  dementia with Parkinsonism (G31.83)  Huntington's disease (G10)  Shy-Drager syndrome (G90.3)  syphilitic Parkinsonism (A52.19)  G21.1 Other drug-induced secondary parkinsonism  G21.11 Neuroleptic induced parkinsonism  Use additional code for adverse effect, if applicable, to identify drug (T43.3X5, T43.4X5, T43.505,T ) Neuroleptic = Major Tranquilizer Haloperidol fits this category Also: Drug Table sends to this

95 Fluid Exchanges 95 Ryder Dennehy


97  Caused by Surge of electrical signals in all/part of brain  Seizure manifestations/duration vary widely  Convulsions, LOC, blank staring, jerky movements  Few seconds to several minutes  Epilepsy dx = 2+ incidents of unprovoked seizure  Many different types of epileptic seizures  30+, one pt may have several types of seizures

98  Localization-related  AKA focal or partial  Specific area of one hemisphere  Simple = still conscious  Complex = Consciousness impaired/LOC  May spread to become generalized  Auras  Generalized  Both hemispheres affected from start of seizure  Tonic clonic (grand mal); Myoclonic; Absence (petit mal); and Atonic  Add’l definition based on  Intractable or Not  w/wo status epilepticus

99  Specificity for  Seizures of localized onset  Complex partial seizures  Intractable -Dr. must document w, w/o  AKA pharmacoresistent, pharmacologically resistant, treatment resistant, refractory (medically), and poorly controlled (acceptable for coding Intractable)  Status epilepticus -Dr. must document w, w/o  Recurrent or continuous for 30+ minutes  Emergency - Can be life-threatening

100  Juvenile myoclonic (JME)  Common – 5% of epileptics  Begins in childhood/adolescence  Multiple Identified genes increase risk  GABRA1 & EFHC1 + others  Seizures more likely w/sleep deprivation/alcohol use  Tonic clonic (grand mal)  Tonic = Stiffening; Clonic = Jerking of limbs and face  Myoclonic  Rapid, brief contractions of muscles  Absence (petit mal)  Lapse of Awareness/staring  Few seconds  Atonic  Loss of muscle tone  Falls, possible injuries

101  Ex: Pt w/ localization-related (focal) (partial) epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy  ICD-10-CM has two possible codes  G40.201, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, with status epilepticus  G40.209, localization-related (focal) (partial) symptomatic epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus  If your Drs don’t note w/ or w/o status epilepticus, start asking for it now  If your Drs don’t note Intractable/Not intractable, start asking for it now

102  62 y-o seen for Tx of recurrent seizures  ICD-10-CM 2013 Index Seizure(s) (see also Convulsions) R56.9 recurrent G  G Epilepsy, unspecified, not intractable, without status epilepticus  Epilepsy NOS  Epileptic convulsions NOS  Epileptic fits NOS  Epileptic seizures NOS  Recurrent seizures NOS  Seizure disorder NOS

103  62 y-o seen for Tx of seizure disorder 2ndary to stroke that occurred 2 yrs ago  ICD-10-CM 2013 Index  Sequelae (of) —see also condition stroke NOS specified effect NEC I  Seizure(s) (see also Convulsions) R56.9 disorder (see also Epilepsy) G  I Other sequelae of cerebral infarction  Alteration of sensation following cerebral infarction  Disturbance of vision following cerebral infarction  Use additional code to identify sequelae  Codes:  I Other sequelae of cerebral infarction  G Epilepsy, unspecified, not intractable, without status epilepticus

104  62 y-o seen for treatment of seizure  ICD-10-CM Index Seizure(s) (see also Convulsions) R56.9  R56 Convulsions, not elsewhere classified  Excludes1:  dissociative convulsions and seizures (F44.5)  epileptic convulsions and seizures (G40.-)  newborn convulsions and seizures (P90)  ICD-10-CM 2013 Tabular  R56.9 Unspecified convulsions  Convulsion disorder  Fit NOS  Recurrent convulsions  Seizure(s) (convulsive) NOS

105  Recurring attacks of moderate to severe throbbing/pulsing pain, often on one side of head  Sensitivity to light & sound  May have N&V  3 X more common in women  Auras = flashing lights/zigzag lines/temporary loss of vision  Precursor  Migraine Triggers  Anxiety  Stress  Lack of food or sleep  Exposure to light  Hormonal changes (in women)

106  Now believed to have genetic cause  Overactive nerve cells responding to low levels of pain  TRESK gene  Diagnosis (International Headache Society)  Type of pain & number of attacks  Minimum of 5 attacks  Duration of 4-72 hours, if untreated

107  Classical migraine = with Aura  Intractable  Terms that describe intractable migraine include: pharmacoresistant or pharmacologically resistant, treatment resistant, refractory, and poorly controlled.  Status migrainosus  Migraine attack >72 hours AND  Severe Intensity

108 Pt (Type 2 Diabetic with neuropathy) with weakness of left arm and leg. Brought to Ed where he could speak but not use left arm/leg. Pt recovered and had no neurologic deficits w/in 24 hrs. During encounter he was also treated for an intractable classical migraine. Dx: TIA G45.9Attack, attacks, transient ischemic (TIA) E11.40Diabetes, diabetic (mellitus) (sugar), type 2, with, neuropathy G Migraine, classical – see Migraine, with aura Migraine, with aura, intractable

109 Alzheimer Disease Frontotermoral dementia Senile Degeneration of Brain NEC Degeneration due to Alcohol Abuse

110  Significant loss of intellectual abilities, such as memory capacity, severe enough to interfere with social or occupational functioning  Criteria for Dx include impairment of attention, orientation, memory, judgment, language, motor and spatial skills, and function  Types of Dementia  Alzheimer – Most common  Vascular  Lewy Bodies  Frontal Temporal (Pick Disease)  Traumatic  Other causes  AIDS  Alcoholism  Brain tumors  Drug toxicity,  Infection  Creutzfeldt-Jakob disease  Meningitis  Syphilis  Hypothyroidism

111  Lewy bodies – accumulated bits of alpha-synuclein protein – inside nuclei of neurons in brain areas controlling particular aspects of memory/motor control  Alpha-synuclein accumulation also linked to Parkinson disease, multiple system atrophy, and several other disorders, - synucleinopathies  Dementia with Lewy Bodies (DLB) 1.3 Million in US  Parkinson 1 million+ in US (with Dementia  Alzheimer 5 million+ in US (4% - Early-onset)  = 6 th leading cause of death

112  Lewy body proteins are found  Area of brain stem where they deplete neurotransmitter dopamine  = Parkinsonian symptoms  Lewy body Dementia - abnormal proteins diffuse thru other areas of brain, inclu. cerebral cortex  Acetylcholine depleted  Disruption of perception, thinking, and behavior (Dementia)

113  Progressive, degenerative disease of brain  Most common form of dementia  Commonly affects elderly  Early Onset/Younger Onset AD – Before 65  Associated w/development of amyloid plaques in cerebral cortex  Characterized by confusion, disorientation, memory failure, speech disturbances, and eventual dementia  Unknown cause  Named for German psychiatrist Alois Alzheimer ( ) (1906 autopsy)

114  Risk of Alzheimer’s doubles about every five years after age 65  After age 85, risk is nearly 50 %  Family hx  Parent, sibling or child w/ Alzheimer’s -more likely to develop  Risk increases if more family members  Heredity  Risk genes – Increase likelihood of disease, but do NOT guarantee  Risk gene with strongest influence is apolipoprotein E-e4  APOE-e4 may be factor in % of Alzheimer cases  Deterministic genes - Directly cause disease, guarantee  Genes coding three proteins: amyloid precursor protein (APP), presenilin-1 (PS-1) and presenilin-2 (PS-2)  Autosomal dominant Alzheimer’s disease (ADAD) or Familial AD  < 5% of all cases  5 more genes related to AD found in 2012

115  Head trauma  May be strong link between serious head injury & risk of Alzheimer’s  Esp. when trauma occurs repeatedly or involves LOC  Buckling seat belt, wear helmet during sports, and “fall-proof” home  Heart-head connection  Every heartbeat pumps about % of blood to head  Brain cells use at least 20% of food and oxygen in blood  High blood pressure cholesterol, Heart disease, Stroke, Diabetes (Insulin Resistance)

116  Amyloid plaques  Neurofibrillary tangles  Loss of neuron connections  Spread to Hippocampus  Mild Cognitive Impairment (MCI)  Cause: Mix of genetic, environmental, and lifestyle factors

117  Stage 1: No impairment (normal function) Person does not experience any memory problems. Interview w/ medical professional shows no evidence of symptoms of dementia  Stage 2: Very mild cognitive decline (may be normal age-related changes or earliest signs of Alzheimer's disease) May feel having memory lapses — forgetting familiar words or location of everyday objects. No symptoms detected during medical exam or by friends, family or co-workers  Stage 3: Mild cognitive decline (early-stage Alzheimer's Dx in some, but not all, individuals w/these symptoms) Friends, family or co-workers begin to notice difficulties. Detailed History by Drs may detect problems in memory/concentration. Common stage 3 difficulties include:  Noticeable problems coming up with right word or name  Trouble remembering names when meeting new people  Noticeably greater difficulty performing tasks in social/work settings  Forgetting material that was just read  Losing/Misplacing a valuable object  Increasing trouble w/planning or organizing

118  Stage 4: Moderate cognitive decline (Mild or early-stage Alzheimer's disease) Careful medical interview able to detect clear-cut symptoms in several areas  Forgetfulness of recent events  Impaired ability for challenging mental arithmetic — for example, counting back from 100 by 7s  Greater difficulty performing complex tasks - planning dinner for guests, paying bills  Forgetfulness about own personal history  Becoming moody/withdrawn, especially in socially or mentally challenging situations

119  Stage 5: Moderately severe cognitive decline (Moderate or mid-stage Alzheimer's disease) Gaps in memory & thinking are noticeable, need help with ADLs  Unable to recall own address/telephone number or high school/college  Become confused about place or what day it is  Trouble w/ less challenging mental arithmetic; such as counting backward from 40 by subtracting 4s or from 20 by 2s  Need help choosing proper clothing for season/occasion  Still remember significant details about themselves and family  Require no assistance with eating or using toilet

120  Stage 6: Severe cognitive decline (Moderately severe or mid-stage Alzheimer's disease) Memory continues to worsen, personality changes may occur & individuals need extensive help w/ADLs. Individuals may  Lose awareness of recent experiences as well as of surroundings  Remember own name but have difficulty w/personal history  Distinguish familiar & unfamiliar faces but trouble remembering name of spouse  Need help to dress properly  Experience major changes in sleep — sleeping in day & restless at night  Need help handling toileting (i.e., flushing toilet, wiping or disposing of tissue)  Increasingly frequent trouble controlling bladder or bowels  Major personality/behavioral changes, inclu. suspiciousness & delusions (believing caregiver is impostor) or compulsive, repetitive behavior  Tend to wander or become lost

121  Stage 7: Very severe cognitive decline (Severe or late-stage Alzheimer's disease) Individuals lose ability to respond to environment, to converse and to control movement. May still say words or phrases.  Need help with much of daily personal care, including eating or using toilet  May also lose ability to smile, to sit w/o support & to hold head up  Reflexes become abnormal. Muscles grow rigid. Swallowing impaired.

122 52-y-o having increased dementia and forgetfulness. Wanders off from his home & forgets where he is & what he is doing. Dx: Dementia due to Early-onset Alzheimer  G30 Alzheimer's disease  Alzheimer's dementia senile and presenile forms  Use additional code to identify:  delirium, if applicable (F05)  dementia with behavioral disturbance (F02.81)  dementia without behavioral disturbance (F02.80)  G30.0 Alzheimer's disease with  early onset  F02 Dementia in other diseases classified elsewhere  Code first underlying physiological condition, such as:Alzheimer's (G30.-)  F02.81 Dementia in other diseases classified elsewhere with behavioral disturbance  Dementia in other diseases classified elsewhere with aggressive behavior  Dementia in other diseases classified elsewhere with combative behavior  Dementia in other diseases classified elsewhere with violent behavior  Use additional code, if applicable, to identify wandering in dementia in conditions classified elsewhere (Z91.83)

123  20 Million alcoholics in US  50% have mild to severe neuropsychological difficulties  Effect depends on multiple variables  Alcohol–induced persisting amnesic disorder  Amount of alcohol consumed  Age began drinking  Duration of drinking  Pt’s age, level of education, gender, genetic background, and family hx of alcoholism  Neuropsychiatric risk factors  Alcohol exposure before birth General health status  Comorbiditieso


125  1 oz of alcohol = 1 drink  128 oz/gallon X 625 g = 80,000 drinks  128 oz/gallon X 20 g = 2,560 drinks  40 years (57-40 = 17 yo) = 480 months  80,000 = 167/mo = 42/wk = 6/day  480  2,560  480 = 5/mo

126  Medical conditions  Malnutrition  Liver and Cardiovascular diseases  Neurological conditions  Head injury,  Encephalopathies  Fetal alcohol syndrome  Psychiatric conditions  Depression  Anxiety  PTSD,  Schizophrenia  Other drug use

127  Neuropsychiatric disorder caused by thiamine deficiency, most often due to alcohol abuse  Combines features of Wernicke's encephalopathy and Korsakoff's syndrome  Korsakoff's syndrome  Syndrome of anterograde & retrograde amnesia wconfabulation associated w/alcoholic or nonalcoholic polyneuritis  Wernick encephalopathy  Common condition in pts w/long-term alcoholism, resulting largely from thiamin deficiency and characterized by disturbances in  ocular motility, pupillary alterations, nystagmus, and ataxia with tremors  AKA superior hemorrhagic polioencephalitis, Wernicke disease

128  Dementia with Lewy Bodies  Dementia symptoms consistent with DLB develop first  REM sleep disorder is more common  Hallucinations, delusions, and misidentification of familiar people  Both dementia symptoms & movement symptoms present at diagnosis  Movement symptoms develop w/in year after DLB Dx  Disruption of ANS  Blood pressure drop on standing, dizziness, falls & urinary incontinence  Parkinson's disease dementia  Movement symptoms first  Dementia symptoms don't appear until year + later

129  Due to cerebrovascular disease, usually with stepwise deterioration  Series of small strokes  Patchy distribution of neurologic deficits affecting some functions and not others  Symptoms include confusion, problems with recent memory, wandering or getting lost in familiar places, bladder or bowel incontinence, emotional problems difficulty following instructions, and problems handling money.  Change is noticeable only as series of small steps  Over time, more small blood vessels in brain blocked, so more noticeable gradual mental decline.  Begins between 60 and 75  Affects men more than women  AKA multi-infarct dementia

130 Any condition causing damage to protective covering (myelin sheath) surrounding nerve fibers in brain and spinal cord Nerve impulses slow or even stop, causing neurological problems

131  Vision or Hearing loss  Headache  Seizures  Muscle spasms and weakness  Loss of coordination  Paralysis  Loss of sensation

132  Most common Demyelination Disease  AKA – Disseminated sclerosis  Thought to be an autoimmune disease  Combination of factors  Infection, Genes, etc. osis.svg

133  Age - can occur at any age, but most commonly 20s – 40s  Gender - Women 2 X more likely  Family hx - 1 parent/sibling = 1-3% chance General Population = 0.10%  Identical twin has 30% chance of getting IF twin has MS  Certain infections - Variety of viruses, such as Epstein-Barr virus and others, appear to be associated with multiple sclerosis.  Ethnicity - White people with North European heritage = highest risk  AAsian, African or Native American descent =  Geographic regions - Europe, southern Canada/northern US, New Zealand & southeastern Australia  Child moving from high-risk area to a low-risk area, or vice versa = acquires risk level of new home.  Move after puberty, young adult usually retains risk level of first home  Other autoimmune diseases -  Thyroid disease, type 1 diabetes or inflammatory bowel disease

134  Optic neuritis w/demyelination  Inflammation or demyelination of optic nerve  AKA retrobulbar neuritis  ~ 66% of people with MS have at least one episode of optic neuritis  Frequently first symptom of MS  One eye at a time, may be pain also  Usually clears in 4-12 weeks

135  AKA Periaxial encephalitis, Schilder disease  Affects children  Dementia, cortical blindness, cortical deafness, spastic hemiplegia, and pseudobulbar palsy

136 Many Classification Systems for Cerebral Palsy ICD-10-CM uses terms Spastic Athetoid Quadraplegic Diplegic

137  Group of nonprogressive disorders of movement and posture  AKA Static encephalopathy  Caused by abnormal development of, or damage to, motor control centers of brain  Events before, during, or after birth  5-10% of CP attributed to birth trauma  Other possible causes include  Abnormal development of brain  Prenatal factors directly /indirectly damaging neurons  Preemature birth – 5 X risk; Mulitiple  Brain injuries in first few years  Most cases are Spastic CP or mixed CP  10,000 new cases in US every year

138  Maternal health  German measles (rubella), viral infection prevented w/ vaccine  Chickenpox (varicella), Viral infection prevented with vaccine  Cytomegalovirus, very common virus causes flu-like symptoms  Birth defects possible if mother has first active infection during pregnancy  Toxoplasmosis, parasitic infection in soil and feces of infected cats  Syphilis  Exposure to toxins, such as methyl mercury  Other conditions  Thyroid problems, mental retardation or seizures

139  Infant illness  Bacterial meningitis  Viral encephalitis  Severe or untreated jaundice  Other factors of pregnancy and birth  Premature birth < 37 weeks = higher risk of cerebral palsy. <28 weeks = 50% chance  Low birth weight < 5.5 pounds (2.5 kilograms) = higher risk, which increases as birth weight decreases  Breech births  Multiple babies. Risk rises number of babies sharing uterus  1+ babies die risk that survivors may have cerebral palsy increases  Low Apgar Score at birth

140  Most common manifestation %  Hypertonia, or muscle tightness  Can affect 1 side of body or just legs  Quadriplegia = all four limbs w/spasticity

141  ~ 25 % of CP  AKA dyskinetic cerebral palsy  Manifests as slow, involuntary muscle movement accompanied by mixed muscle tone  Some muscles have too high tone, while others too low

142  Least common type of CP  %  Characterized by poor muscle tone and difficulty coordinating movements in arms, legs and torso (Cerebellum)

143  10 % of CP  Several different types of CP in one individual  Most common combination (~ 10 percent of all mixed CP cases)  Spastic & athetoid movements together  All other combinations are also possible, but rarer


145  Excessive accumulation of fluid in brain  Water on the Brain - actually CSF  Ventricles abnormally widen – pressure on tissues  Blockage of normal CSF flow or absorption  Congenital OR Acquired  Communicating OR Non-communicating  Hydrocephalus ex-vacuo  Compensatory replacement by CSF of volume of tissue lost in brain atrophy  NPH  Normal Pressure Hydrocephalus p?title=File:Hydrocephalus.jpg

146  Dilatation of cerebral ventricles, usually occurring 2ndary to obstruction of CSF pathways  Accumulation of CSF w/in skull  Typically enlargement of head, prominence of forehead, brain atrophy, mental deterioration, and convulsions  Communicating  Free access of fluid between ventricles brain and spinal canal  Non-communicating (AKA Obstructive)  Due to obstruction of CSF flow within brain ventricles or through their exit foramina

147  CSF balance disrupted  May cause normal pressure hydrocephalus  Ventriculmegaly  Most often in older people  Idiopathic OR 2ndary  May be result of traumatic fall or injury or illness  Can sometimes be reversed (Shunt)  S&S  Gait and balance problems  Urinary incontinence  Dementia le:Hydrocephalus.jpg


149  Brain tumors more common than spinal tumors  B9 or malignant  Almost ½ of brain tumors are B9  Can recur, be fatal  Brain common site for 2ndary metastatic brain tumors (from lung, breast ca, etc.)

150  Most common type of nervous system tumors  Connective tissue differentiates  Astrocytoma  Brain stem glioma  Ependymoma  Oligodendroglioma  Medullablastoma  Meningioma  Neuroma

151  Most common glioma ~1/2 of all primary brain & spinal cord tumors  Most often in cerebrum  Classification  Low grade astrocytomas (10%)  Anaplastic astrocytomas  Glioblastomas Anaplastic astrocytoma Before and After Surgery, Radiation, and Chemo

152 Brain stem glioma  Low grade to high grade  Most often in children y-o (75%)  Can occur in adults

153  Rare type of glioma (85% B9)  Thought to develop from precursor cells to ependymal cells lining ventricles and central canal of spinal cord  3rd most common form of pediatric brain tumors  3-6 % CNS tumors in adults  5% of gliomas in adults, mostly in spine  Slightly higher incidence rate in Males & Whites  Usually arise from floor of 4th ventricle  Can cause Hydrocephalus Ependymoma

154  Develops from glial cells (2% of brain tumors)  Occurs frequently in frontal/temporal lobes  Can be classified as low grade or high grade  Common in males and females y-o  More common in men than women  Can occur in children  Low to High Grade  B9  Malignant Oligodendroglioma ndroglioma_002.jpg CT

155  Most common at midline of cerebellum & roof of 4 th ventricle  25% of all pediatric brain cancers  Presents w/ N&V, headache, ataxia, papilledema, nystagmus, irritability, lethargy, cranial nerve palsy, dizziness, altered vision  If cells get into CSF, medulloblastoma can spread to other areas of CNS -282X &script=sci_arttext

156  B9, slow-growing tumor of meninges, usually next to dura mater  May invade skull or cause hyperostosis  Often causes increased intracranial pressure  Most common in Adults  Usually vascular  After radiation  2 X more common in women  WHO classification  Grade I: Benign Meningioma  Grade II: Atypical Meningioma  Grade III: Malignant (Anaplastic) Meningioma f/fb/Contrast_enhanced_meningioma.jpg Contrast-enhanced CT of Brain

157  General term for any neoplasm derived from cells of nervous system  Acoustic neuroma  AKA Vestibular schwannoma  Slow-growing B9 tumor of nerve connecting ear to brain (VIII Cranial)  Can damage several important nerves as enlarges  S&S usually begin in 30s


159  Disruption of normal brain function  Caused by bump, blow or jolt to head or penetrating head injury  1.7+ million every year in US  75% mild (concussion)  ~18% of all TBI-related ED visits involved children aged years  ~22% of all TBI-related hospitalizations involved adults 75 years +  Males more often diagnosed with TBI (59%).

160 TBI Causes

161  Leading cause of TBI in US  50% of TBIs among children years  61% of all TBIs among adults 65 years + not_wearing_fall_protection_equipment.jpg

162  In all age groups, MVAs & traffic-related incidents 2nd leading cause of TBI (17.3%)  Largest percentage of TBI-related deaths (31.8%)  2.3 million+ adult drivers/passengers treated in EDs due to MVAs in 2009  Lifetime costs of crash-related deaths/injuries for drivers/passengers = $70 billion in 2005

163  Hematoma - collection of blood outside of blood vessel  Epidural  Subdural  Intracerebral  Concussion  Cerebral Contusion  Basilar Skull Fx

164  Trauma, often to temple  Middle meningeal artery  Accumulation of blood epidural space  Outside (Above) Dura Mater  Due to Dura’s attachment to skull, small hematomas can cause significant pressure  1- 3% of head injuries  15-20% are fatal :Epidural_Hematoma.jpg

165  Collection of blood on brain’s surface  Due to ruptured veins  Acute Subdural = one of deadliest head traumas  Serious head injury  Bleeding rapidly puts pressure on brain tissue  Chronic Subdural = common in elderly  Can be cause by minor injury (Fall)  Can be unnoticed for days/weeks  Shrinking brain = more space :Subduralandherniation.PNG

166  Within brain tissue  Caused by bleeding from  Uncontrolled high blood pressure  Aneurysm leak or rupture  Trauma  Tumor  Stroke al_heamorrage.jpg

167  L, concutere, to shake violently  Trauma-induced loss of consciousness, transient or prolonged  Due to a blow to head; may be transient amnesia, vertigo, nausea, weak pulse, and rapid/slow respiration oncussion_mechanics.svg

168  Bruise of Brain tissue  20–30% of severe head injuries  Cerebral laceration is similar  BUT pia-arachnoid membranes are torn over Injury site  Contrecoup contusion  Blow on one side of head with damage on opposite side by transmitted force

169  Fx involving base of cranium  S&S May be asymptomatic  Raccoon eyes  Battle sign  Hemotympanum  CSF Rhinorrhea  Imaging: Plain skull film may not reveal fx  CT or MRI more reliable cy/imagepages/3067.htm

170  Trauma  Disease  Common symptom = Ataxia  Lack of muscle coordination  Speech pattern changes  Abnormal gait

171  Trauma can be fatal when Reflex centers damaged  Non-fatal injuries  Cranial nerve malfunction  Paralysis  Loss of sensation  Respiratory Irregularities

172  TBI in early/midlife = increased risk of dementia in late life  Moderate/severe TBIs = 2-4 X increased risk  People < 50 y-o  Head injury is 3rd most common cause of dementia, after infection and alcoholism  Most common causes of head injury  MVAs (50%)  Falls (21%)  Assault or GSW (12%)  Sports - boxing (dementia pugilistica), other recreational activity (10%)  Use of alcohol/substances factor in ~1/2  Children  Bicycle accidents  Infants  Shaken baby syndrome  Elderly persons  Especially falls

173 173 Select at least TWO of the following sites and review the brain pathologies of your choice Complete the Post -Test

174  Brain Tour. Alzheimer’s Association.   Brain Cancer. X-plain Module.  m m  Khurana, V. Brain Tumor Education Resource. 2 Tutorials.   Hulman, G. Cerebral Ischaemia and Infarction. Pathology mini- tutorial. Nottingham University Hospitals.  ms3/Cerebral_ischaemia_and_infarction___Medium.mp4 ms3/Cerebral_ischaemia_and_infarction___Medium.mp4  Brain Aneurysms. Toronto Brain Vascular Malformation Study Group 

175  Parkinson’s Disease. X-plain module.   Seizures & Epilepsy. X-plain module   mild Traumatic Brain Injury. US DOD   Traumatic Brain Injury. X-plain Module.   Getting It: A Disease... A Vaccine. National Meningitis Association. Video in 3 parts, 25 min. total. 

176  Brain Quiz. AARP.  quiz.html quiz.html  Alzheimer's disease and other types of dementia.  other-types-of--dementia html other-types-of--dementia html  What Do You Know About Alzheimer's Disease? Yale Medical Group. 10 questions.   Howe, M. How Much Do You Know About Epilepsy? 10 questions.  About-Epilepsy html About-Epilepsy html

177  Brain Injury Awareness Quiz - HensonFuerst, Raleigh Brain Injury Lawyers. 8 questions   Brain Attack.  html html  Stroke Quiz: Test Your Medical IQ. eMedicineHealth.   You've Probably Never Heard of It.  Heard-of-It html Heard-of-It html

178  Take the Huntington's Disease Quiz. University of Rochester Medical Center. 8 questions.  tTypeID=40&ContentID=HuntingtonDiseaseNeuQuiz tTypeID=40&ContentID=HuntingtonDiseaseNeuQuiz  Health Library. Quizzes. Roper St. Francis Healthcare.   Meningitis Quiz: Test Your Infectious Disease IQ. eMedicineHealth. 

179 1.Motor 2.Myelinated nerve fibers 2.Limbic system 3.Carries signals from the outer parts of the body to the CNS 4.Cerebrum 5.Gyri 6.Cerebellum 7.Medullar Oblongata 2.20% 3.Brainstem 4.Pineal Gland Smell 7.Ventricular 8.12 C.Exocrine system. D.Limbic system.

180 180

181  Medical Dictionary. The Free Dictionary.   Brain and Nerves. MedlinePlus.   Hulman, G. Pathology mini-tutorials. Nottingham University Hospitals.   McGuire, N. ICD10 Session 11 Chapter 6. Codapedia. 32 Min. video  of-the-Nervous-System.cfm of-the-Nervous-System.cfm  WebMD. Brain & Nervous System Health Center   WebMD. Medical References Related to Brain & Nervous System 

182  Alzheimer's Disease. Alzheimer’s Association. Includes Videos.   Alzheimer's Disease Fact Sheet. NIA (NIH).  -disease-fact-sheet -disease-fact-sheet  Peterson, R. Mild Cognitive Impairment Research. 20 min. Video. HBO, NIH, Alzheimer’s Assoc.  d_media_identifying.asp d_media_identifying.asp

183  Aneurysm in the brain. MedlinePlus.   Brain aneurysm. Mayo Clinic.  What You Should Know About Cerebral Aneurysms. American Stroke Association.  HemorrhagicBleeds/What-You-Should-Know-About-Cerebral- Aneurysms_UCM_310103_Article.jsp HemorrhagicBleeds/What-You-Should-Know-About-Cerebral- Aneurysms_UCM_310103_Article.jsp

184  Howard, A. Coding for Seizures and Epilepsy. For The Record, Vol. 24 No. 10 P. 28, 5/21/2012   Bielby, J. A. Diagnosis Coding of Seizures, Epilepsy and Other Related Terms. CodeWrite, 11/2011.  zures.html zures.html  Leppert, M. Epilepsy codes in ICD-10-CM requires additional documentation. 7/20/2012.  requires-additional-documentation/ requires-additional-documentation/  MedlinePlus. Epilepsy.   Epilepsy Foundation. Types of Seizures.  sy/Types-of-Seizures.cfm sy/Types-of-Seizures.cfm

185  Astrocytoma Tumors. American Association of Neurological Surgeons.  ns%20and%20Treatments/Astrocytoma%20Tumors.aspx ns%20and%20Treatments/Astrocytoma%20Tumors.aspx  Ependymoma Overview. Collaborative Ependymoma Research Foundation (CERN). 

186  Parkinson's disease and Parkinsonism: Are they the same thing? Parkinson’s Action Network.  disease-and-parkinsonism-are-they-same-thing disease-and-parkinsonism-are-they-same-thing  Parkinson's disease. Mayo Clinic.  disease/DS disease/DS00295  Understanding Parkinson’s Disease. Medical News Today. Video, 3 minutes.  autodetect.aspx?content_id=2856&focus_handle=parkins ons-disease&brand_name=medicalnewstoday autodetect.aspx?content_id=2856&focus_handle=parkins ons-disease&brand_name=medicalnewstoday

187  Am I at risk for a stroke? Nat’l Stoke Association.   Coding for Cerebral Infarction. For The Record Vol. 21 No. 21 P. 24   Coding Sequelae of Cerebrovascular Disease in ICD-10-CM. CodeWrite, August AHIMA.  uelae.html uelae.html  Effects of Stroke. Wexner Med. Ctr. Ohio State Univ.  effects/Pages/index.aspx effects/Pages/index.aspx  Stroke. MedlinePlus   Stroke. Medical Dictionary. 

188  Stroke – Rehabilitation. – Joint project of Cardiovascular Research Foundation, Office on Women's Health, DHHS and WomenHeart: the National Coalition for Women with Heart Disease.  5.html 5.html  What Are the Effects of a Frontal Lobe Stroke? About. Com Source: Allan Ropper and Robert Brown, Adam's and Victor's Principles of Neurology, 8th Edition McGraw-Hill Companies Inc, United States of America, 2005, pp   What is a stroke? Nat’l Heart, Blood, and Lung Institute. NIH.  index.html index.html

189  Division of Disability and Aging Services. Vermont. Traumatic Brain Injury. 3 tutorials with workbooks and quizzes.  default-page default-page  Injury Prevention & Control: Traumatic Brain Injury. CDC.   Wedro, B. Hematoma. MedicineNet.   Brain Injury Guide and Resources. Missouri DHSS and MU DH. CEUs. 

190  Acoustic neuroma. MedlinePlus.   Gray, L. ICD-10-CM Diagnosis Coding for Pain Medicine. CodeitRight Insights. 3/5/2013.  coding-for-pain-medicine.html coding-for-pain-medicine.html  Hereditary Spastic Paraplegia Information Page. NINDS. NIH.  ary_spastic_paraplegia.htm ary_spastic_paraplegia.htm  Hydrocephalus Fact Sheet. NINDS. NIH.  cephalus.htm cephalus.htm

191  Multiple sclerosis. Mayo Clinic.   Oscar–Berman, M., Marinkovic, K. Alcoholism and the Brain: An Overview. NIAAA, NIH.   Pfefferbaum, A. Sullivan, E. V, Mathalon, D. H., & Lim, K. O. Frontal lobe volume loss observed with magnetic resonance imaging in older chronic alcoholics. Alcoholism: Clinical and Experimental Research 21:521–529, 

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