Patient is a 33-year-old white female who has suffered from TMJ syndrome for a number of years. She consulted an orthodontist and found that she has cross-bite. In working her up for braces, the orthodontist found that her upper jaw was too small and that he could not guarantee that, the braces would correct the cross-bite. He referred her to an oral surgeon. The oral surgeon's examination showed
that the patient's upper jaw was, indeed, too small. He recommended a maxillary corticotomy with rapid palatal expander in order to correct the jaw deformity. The patient agreed to the surgery. Her primary care physician for her pre-op history and physical saw her. He has been treating her for the TMJ syndrome, hypertension, and celiac disease, in addition to the maxillary hypoplasia. She is undergoing the corticotomy today.
First-listed diagnosis: ________
Secondary diagnoses: ________
Fill in the blank with correct word.
First-listed diagnosis: ________
Answer: Maxillary hypoplasia – M26.02
Secondary diagnoses: ________
Answer: TMJ syndrome – M26.60; hypertension – I10; Celiac disease – K90.0
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