**Diagnosis:  Gastroesophageal Reflux Disease (GERD) - ICD-9 530.81 to ICD-10 K21.9**

Patient presents with complaints consistent with gastroesophageal reflux disease (GERD).  Symptoms include heartburn, acid reflux, regurgitation, and dyspepsia.  Patient reports postprandial burning sensation in the chest and throat, often exacerbated by lying down or bending over.  Symptoms occur several times a week and interfere with sleep and daily activities.  Differential diagnoses considered include esophageal spasm, peptic ulcer disease, and angina.  Physical examination reveals no significant abnormalities.  Assessment supports a diagnosis of GERD.  Plan includes lifestyle modifications such as dietary changes, weight management, and elevation of the head of the bed.  Patient education provided on avoiding trigger foods and maintaining a healthy weight.  Pharmacological management initiated with a proton pump inhibitor (PPI) for symptom control.  Follow-up scheduled to assess response to therapy and adjust treatment plan as needed.  ICD-10 code K21.9 (Gastro-esophageal reflux disease without esophagitis) assigned based on the presenting symptoms and clinical findings.  ICD-9 code 530.81 documented for historical comparison and medical billing accuracy.  Keywords: GERD, heartburn, acid reflux, regurgitation, dyspepsia, PPI, proton pump inhibitor, esophageal spasm, peptic ulcer disease, angina, K21.9, 530.81, ICD-10, ICD-9, medical coding, medical billing, healthcare, clinical documentation, electronic health record, EHR.


**Diagnosis:  Acute Bronchitis - ICD-9 466.0 to ICD-10 J20.9**

Patient presents with a productive cough, chest congestion, and shortness of breath.  Onset of symptoms occurred three days ago and has progressively worsened.  Patient denies fever, chills, or body aches.  Physical examination reveals coarse breath sounds and mild wheezing.  No signs of pneumonia or other respiratory distress are observed.  Diagnosis of acute bronchitis is made based on clinical presentation.  Differential diagnoses included influenza, pneumonia, and asthma.  Treatment plan includes supportive care with increased fluid intake, rest, and over-the-counter cough suppressants.  Patient education provided on proper hygiene and prevention of transmission.  No antibiotics are indicated at this time.  Follow-up recommended if symptoms do not improve within one week or worsen.  ICD-10 code J20.9 (Acute bronchitis, unspecified) assigned.  Previous ICD-9 code 466.0 documented for completeness and accurate medical record keeping. Keywords: acute bronchitis, cough, chest congestion, shortness of breath, wheezing, influenza, pneumonia, asthma, J20.9, 466.0, ICD-10, ICD-9, medical coding, medical billing, healthcare, clinical documentation, electronic health record, EHR.