Case Studies: This 49-year-old female patient is stabilized after having surgery for choledocholithiasis with acute cholangitis and obstruction. She has been able to drink fluids and has voided. She is to follow up in my office in 7 days. ICD-10-CM Code: This patient was admitted yesterday and was referred to me by Dr. Jones. Dr. Jones ordered an abdominal scan that confirmed an acute gastric ulcer hemorrhage. I explained to the patient that I will be ordering additional diagnostic tests and she will be given antacids. I will see her later when the results of the lab work are available. ICD-10-CM Code: This 39-year-old patient was referred to me because she has strangulated 4th-degree hemorrhoids. Conservative treatment has not been successful. She wants to discuss surgery. I explained the benefits and the risks, and she gave consent for surgery. Surgery will be scheduled within 1 week. ICD-10-CM Code: This 26-year-old male patient is being seen today to follow up on his Crohn's disease. At this time, he is being managed with medications. He states that over the last 2 months he has not had any acute exacerbations. At this time, we will continue the current course of treatment. I will see him if symptoms develop or in 3 months. ICD-10-CM Code: This 37-year-old male patient presents today complaining of groin pain. He reports that his pain increases when he lifts and the pain subsides when he lies down. CT scans confirm a diagnosis of inguinal hernia. ICD-10-CM Code:
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The first patient has choledocholithiasis with acute cholangitis and obstruction. The ICD-10-CM code for this condition is K80.20. Show more…
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CASE STUDY Khadija Mahmood is a 26-year-old woman complaining of abdominal pain. The following data are collected by the nurse during an interview and examination. Interview Data Ms. Khadija tells the nurse that the pain started yesterday evening and has gotten progressively worse. She describes the pain as "really bad." It is constant and located in her right lower abdomen, toward her umbilicus. She says that it feels a little better if she stays curled up and does not move. She tells the nurse that she is in good health and that she has never had a problem with her stomach. Ms. Khadija indicates that normally she has a good appetite and can eat anything - except for now. She says that she ate breakfast and lunch yesterday but by dinnertime she was nauseated and had no appetite. She has not eaten anything since. She has had no recent weight changes, but she would like to weigh about 2.5 kg less than she currently does. Ms. Khadija smokes a half pack of cigarettes daily. She does not drink alcoholic beverages, and she takes no medication. She denies discomfort or problems with urination, describing her urine as "usual looking." Examination Data - General survey: Alert and anxious female in moderate distress lying in a fetal position on the examination table, with her eyes closed. Appears well nourished. Her skin is hot. - Inspection: Abdomen is flat and symmetric. No lesions or scars are noted. No surface movements are seen except for breathing. - Auscultation: Bowel sounds are absent. - Palpation: Tympany is noted over most of the abdominal surface, dullness over liver. Midclavicular liver span is 10 cm. - Light palpation: Demonstrates pain and guarding in right lower quadrant. Unable to palpate deep structures because of excessive abdominal discomfort. Demonstrates positive rebound tenderness in right lower quadrant. Clinical Reasoning 1. Which data deviate from normal findings, suggesting a need for further investigation? For which additional information should the nurse ask or assess? 3. Based on the data, which risk factors for cancers in the abdomen does Ms. Khadija have?
Madhur L.
A 25-year-old white female reports to the Emergency Room because of sharp left-sided chest pain and shortness of breath of one-day duration. The patient was in excellent health until yesterday. She was awakened from her sleep by sharp left-sided chest pain. The pain worsened with motion and deep breathing. The pain has been progressively increasing in severity, and she now has severe left shoulder pain. She complains of shortness of breath and is very apprehensive about dying. She denies any cough, fever, sputum production, or hemoptysis. She is married and had one normal delivery three years ago. She is currently on birth control pills. She has never been hospitalized except for labor and delivery. Review of systems is negative. She denies any past history of venous problems. She reveals having a similar transitory minor episode of chest pain approximately one year ago while she was vacationing in Michigan. She works as a computer programmer. She smokes one pack of cigarettes a day for the past eight years. She considers herself a social drinker. What can you reasonably conclude given the above information: (select all that apply) A. She is at risk for a cerebral vascular accident due to brain embolism if the DVT moves to her brain. B. Her history, signs, and symptoms are consistent with a pulmonary embolism due to an embolized DVT. C. Smoking and a sedentary job that requires hours of sitting have increased her risk for deep vein thrombosis. D. Underlying pathology was most likely due to turbulence (vs stasis) of venous flow. E. If blood flow from the right ventricle is significantly impeded, as in a saddle thrombus, she could be at risk for cardiovascular collapse.
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