HEALTH SCI HI255-02 Medical Coding II UNIT 7 LAB QUIZ -Questions and Answers (172 Pages)

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George McKeown, a 65-year-old male, presents with pain around his right eye and sensitivity to bright light. Dr. Zabawa notes redness of the eye and sagging skin around the lower eyelid. George is ... diagnosed with entropion of the right eye, lower eyelid……H02.002 John Di Toma, a 10-month-old male, was diagnosed with congenital bilateral cataracts several weeks ago. John is admitted today for the surgical removal of the cataracts Latoya Simpkins, a 36-year-old female, presents with the complaint of right ear pain. Dr. Herauf also documents a low-grade fever, cough, and nasal drainage. Dr. Herauf completes an examination with otoscope, which visualizes a cloudy bulging eardrum with blisters. Latoya is diagnosed with bullous myringitis Kyle Oldenberg, 65-year-old male, presents today with the complaints of gradual loss of vision OD of a 2-month duration. Kyle states it doesn’t hurt, “just getting to where I can’t see.” Kyle saw his ophthalmologist and was diagnosed with angle closure glaucoma and was referred to us for treatment. Attending Physician: Oscar R. Prader, MD Patient is a 49-year-old male diagnosed with chronic acid reflux. Barium swallow fluoroscopy, esophageal pH probe, esophageal manometry, and esophagoscopy were completed. He presents today to discuss the results of those tests. I explain that the test results indicate that he has GERD. The first course of treatment is to adopt a lowfat, high-fiber diet. The second course would be surgical repair. Patient was instructed not to eat at least 2 hours before going to bed, and the head of the bed should be elevated 6 to 8 inches while in supine position. Patient was informed that surgery may be necessary if diet and positioning do not relieve symptoms. Attending Physician: Renee O. Bracker, MD S: Lynne, a 37-year-old female, presents today with the complaint that her right ear is throbbing. O: T: 101, BP: 137/83, R: 21, P: 78. PERRLA. Lynne is in moderate discomfort. She admits to a pain level of 4 on a scale of 0–10. Past medical history: noncontributory. Review of systems: negative. Medications: none. Ear exam: Left is within normal range. Right pinna: a lump is noted, as well as swelling and inflammation. It appears to be a localized pool of blood. Dr. Bracker evacuates the blood and applies a pressure bandage. A: Auricle hematoma Attending Physician: Oscar R. Prader, MD S: This is a 39-year-old male with advanced human immunodeficiency virus infection who has presented to the emergency department with severe itching with a duration of approximately 10 days. On a scale of 1 to 10, he rates the itching as 10 of 10 in severity. Patient states he has been compliant with his antiretroviral therapy. He has been drinking excessively and taking diphenhydramine every 4 hours for the last several days. O: H: 6’1”, Wt: 176, T: 98.9, R: 19, P: 66, BP: 132/76. On examination, he is constantly scratching his skin. There are spots of blood on his clothing. Xerosis is noted as well as several brown patches on his extremities. The scrotum appears leathery and thickened. A skin scraping for scabies mite is performed and sent to the lab for analysis. Attending Physician: Renee O. Bracker, MD S: This 46-year-old female with a 3-month history of ulcerations and abscesses involving both breasts was admitted today. Patient states the ulcerations began to appear after breast reduction surgery, approximately 2 weeks postop. The patient had no history of ulcerations before the breast reduction surgery. She also states that her muscles and joints ache The patient is a 29-year-old female suffering with burning on urination. She stated she also noticed a fishy odor after urination. The urinalysis and culture lab results showed positive for acute pyelonephritis caused by E. coli. She was referred to me. I then admitted her to the hospital for treatment with Ceftazidime-Avibactam Anti-infective, peripheral vein introduction. HISTORY OF PRESENT ILLNESS: This is a 39-year-old previously healthy female. She awoke this morning with pain in her abdomen. Her pain continued, periumbilical, and apparently now has traversed to the right lower quadrant. On a 1 to 10 pain scale she states a 7 for pain. She has had some nausea and vomiting. No history of inflammatory bowel disease, colon cancer, abdominal operations, or bleeding. No urinary tract symptomatology. White blood count is 25, otherwise unremarkable. An ultrasound of the appendix was performed. The patient has clear-cut possible retrocecal appendicitis. RECOMMENDATIONS/PLAN: The patient has received antibiotics. The patient has consented to a laparoscopic, possible open, appendectomy. She was counseled concerning the benefits and risks of the surgery, including but not limited to bleeding, infection, death, and injury. All questions were answered and she agreed to the procedure. We will place bilateral sequential compression devices and call the operating room to have her scheduled as soon as possible. Principal Procedure: [Show More]

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