What ICD-10 codes are appropriate for a 46-year-old male with a history of acute left epididymitis, currently experiencing moderate urinary retention, nocturia, and occasional left flank pain, with a past medical history of spinal surgery and tobacco use, and currently taking Flomax (tamsulosin) 0.4 mg daily?

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From the FDA Drug Label

The provided drug labels do not contain information directly relevant to determining the appropriate ICD-10 codes for the patient's visit.

The FDA drug label does not answer the question.

From the Research

The most appropriate ICD-10 codes for this patient's visit are R33.8 (Other urinary retention), N40.1 (Benign prostatic hyperplasia with lower urinary tract symptoms), N45.9 (Epididymitis, unspecified), and R10.9 (Unspecified abdominal pain) or N23 (Unspecified renal colic), along with Z87.440 (Personal history of urinary system disorder), Z98.89 (Personal history of surgery), and F17.210 (Nicotine dependence, cigarettes). These codes are chosen based on the patient's current symptoms of moderate urinary retention, nocturia, and occasional left flank pain, as well as his history of left epididymitis, spinal surgery, and tobacco use. The patient's medication management with Flomax (tamsulosin) 0.4 mg daily for his urinary retention and likely benign prostatic hyperplasia is also considered. The combination of urinary retention, nocturia, and flank pain suggests possible bladder outlet obstruction with potential upper urinary tract involvement, making accurate coding important for proper documentation and treatment planning, as discussed in the management of lower urinary tract symptoms suggestive of benign prostatic hyperplasia 1. The use of alpha(1)-adrenoceptor antagonists like tamsulosin has been shown to provide effective and rapid relief of symptoms and improvement in quality of life, which is sustained in the long term 2. Additionally, the patient's history of epididymitis and current symptoms of urinary retention and nocturia are consistent with the diagnosis of benign prostatic hyperplasia with lower urinary tract symptoms, as described in the evaluation and treatment of this condition 3. Overall, these ICD-10 codes comprehensively capture the patient's current urinary symptoms, relevant history, and ongoing medication management.

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This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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