Urinary stress incontinence

A five-month old female was brought by her mother to the pediatrician’s office for her scheduled “Synagis” shot. Synagis is a medication given prophylactically to high risk infants to protect them from acquiring the respiratory syncytial virus (RSV) and avoid an acute respiratory illness. The physician’s progress note for the visit concludes with his impression of “ex-30 week premature infant here for Synagis injection, subcutaneous, completed.”


First listed diagnosis ______________


secondary diagnoses ____________


2. A 52-year-old female was admitted to the hospital with urinary stress incontinence and is scheduled for surgical repair of a paravaginal cystocele. An open anterior colporrhaphy is performed to repair the cystocele that was causing the urinary stress incontinence. The patient has type 2- diabetes on oral anti-diabetic medication and central vertigo that is also treated during the hospital stay.


Principal diagnosis ________________


Secondary diagnoses ______________, _________, ____________,____________


3. The patient is a 59- year-old female who is admitted to the hospital after complaining of weakness and for her cycle of chemotherapy. She has a primary malignancy of the transverse colon. On admission, blood work performed indicated severe anemia. The oncologist documented that the anemia was associated with malignancy. Chemotherapy was cancelled. The patient received a transfusion via a peripheral vein of (nonautologous) packed red blood cells and was discharged.


Principal diagnosis ______________


secondary diagnoses ___________


4. A 30- Year-old male was brought to the emergency department by police who found him walking down the middle of a highway. The patient was obviously intoxicated and initially uncooperative, experiencing visual hallucinations. Based on the physical examination and laboratory work, and with information later provided by the patient, the physician concluded the patient had impending delirium tremens that required admission. He also monitored for nicotine withdrawal, as he smoked two packs of cigarettes daily. He was administered a nicotine patch and did not experience nicotine withdrawal. The patient’s discharge diagnosis was delirium tremens and psychotic disorder/hallucinations due to alcohol dependence and nicotine dependence.


Principal diagnosis ________


Secondary diagnoses _____________, ______________


5. The patient is a 77-year old female who is a resident of a nursing home. She had a stroke 10 months ago since that time has had several seizures that have been determined to be a consequence of her stroke. None of the seizures has been very significant, but the patient has been placed on anticonvulsant medication. In the last progress note documenting his visit, her physician wrote the diagnosis of “Patient state, seizure disorder over the past nine months due to her previous stroke.”


Principal (Nursing home) diagnosis ____________________


secondary Diagnoses ______________________


6. A 22- year-old female presented to the Family Practice Clinic after being told told she should see her physician because her partner had recently been treated for nongonococcal urethritis. The woman did not have any complaints other than some vague pelvic discomfort and vaginal discharge that she did not consider serious. A physical examination, pelvic examination, and Papanicolaou test (Pap smear) were performed. Based on her history and physical findings, the patient was diagnosed with acute chlamydial cervicitis and given a prescription for two weeks of antibiotic oral medications and an appointment for a follow-up examination in three weeks.


First- Listed Diagnosis _____________________________


7. An 18-year-old female patient who has had type 1 diabetes for 10 years was admitted with ketoacidosis. She has an insulin pump. The pump was tested and found to have a break-down; it was not pumping enough insulin, so there was an underusing of the insulin, which is what caused the ketoacidosis. With intravenous hydration and insulin drip, the patient’s ketones cleared quickly. The insulin pump was reset to the correct dosage.


Principal diagnosis _________________


Secondary diagnoses ________________, ___________________


8. Patient was a passenger on a commercial (fixed wing) airplane flight who was injured when the plane experienced a forced hard landing at the city public airport. Patient was flying to a vacation destination.


External cause code (s) ____________, _____________, ____________


9. A Patient is seen in the eye clinic at the University Medical Center. After taking a thorough history and conducting an extensive physical eye examination, the physician orders several tests to be done over the next week. At the conclusion of the visit, the physician writes the diagnosis of mild primary open angle glaucoma, bilateral.


First listed diagnosis ____________


10. Family members bring a 19- year old male to the hospital emergency department. The patient had stated he had a severe headache, fever, and nausea and vomiting. A thorough physical examination and diagnostic imaging was performed. The physician arranges for the transfer of the patient to a larger hospital with the diagnosis of “Rule out meningitis.” all records and test results, are transferred with the patient. In addition to the physical complaints states by the patient, the physician adds the diagnoses of possible meningismus or possible meningitis.


First-listed diagnosis _________


Second diagnoses _______________, _______________


11. Driver injured in a motor vehicle collision with another vehicle on a highway. Patient is an employed driver for a delivery company.


External cause code(s) _____________, ____________, _____________


12. The patient is a 53- year-old female with left breast cancer, metastatic to the bone and brain, all diagnosed in the past six months with continued management. The patient is seen in the hospital’s outpatient oncology clinic for her next cycle of intravenous infusion, through a peripheral vein, of Aredia, a chemotherapy drug used as palliative treatment for bone metastases.


First listed diagnosis ________________


Secondary diagnoses ___________, ___________, ___________


13. An 85- year-old female was brought to the family physicians office by her family to better treat the symptoms of her severe dementia due to Alzheimer’s disease. She is becoming increasingly difficult to manage at home. At times, she becomes aggressive and attempts to strike family members with household objects. She also has repeatedly wandered away from the home’s backyard  and has had to be located by calling police to assist in the search. The family members will continue to care for the woman in their home. The physician’s diagnosis is late onset Alzheimer’s dementia with behavioral disturbances such as aggression and wandering.


First-Listed diagnosis _______________


Secondary diagnoses ________________, _________________


14. The female older adult patient is seen in the orthopedic clinic for a complaint of muscle wasting or atrophy of the lower legs. In conducting a thorough history and physical examination, the physician learns that the patient had poliomyelitis more than 65 years previously. The physician determines the muscle atrophy is a result of her old polio and describes it as post polio syndrome. The physician recommends a trial of physical therapy in the future to prevent further muscular wasting.


First-listed diagnosis _________


Secondary diagnoses __________, ______________


15. A 38- year-old male with known chronic viral hepatitis resulting from hepatitis B is seen in the outpatient infectious disease clinic to be evaluated for therapy. The patient also has cirrhosis of the liver with suspected early stages of liver failure. His liver disease continues to be monitored. The patient is a known heroin addict in remission and has been taking methadone faithfully on a long term basis through a program at this university medical center. All of these factors were considered when a combination of antiviral agent interferon-alpha plus lamivudine treatment was chosen and will be initiated at his next visit, scheduled in 1 week.


First listed diagnosis _______________________


secondary listed diagnoses ________________, ___________________


16. A patient with terminal carcinoma of the sigmoid colon with metastases to the liver was admitted to the hospital with hypotonic dehydration. The patient’s dehydration was deemed by the attending physician to be due to the malignancy. The dehydration was the focus of the treatment with intravenous therapy, but the patient was also treated for hyponatremia and the patient felt relief from his symptoms. Chemotherapy had been recently discontinued after discussions with the patient about its ineffectiveness in curing his disease and how sick the treatment made the patient feel. During the hospital stay, the patient and his family agreed to palliative care only, which was ordered along with an order to “do not resuscitate”. The patient was discharged to home to consider electing hospice services.


Principal diagnosis: _________________


Secondary diagnoses:  ________, _______, _______, ________, ________


17. A 6-month-old infant, born with a congenital anomaly of the inner ear with impairment of hearing, is admitted for surgery to treat his mixed hearing loss. The patient is taken to surgery to place bilateral single channel cochlear prosthesis (hearing) implants via an open approach. He quickly recovers from the procedure and anesthesia and is discharged home.


Principal diagnosis _________


Secondary diagnoses _______________


18. A 20- Year-old African-American male is admitted to the hospital from the emergency department with acute vast-occlusive pain and pulmonary symptoms including shortness of breath, chills, and cough. He was known to have Hb-SE sickle-cell disease. A chest x-ray showed new pulmonary infiltrates. Treatment was focused on reducing the chest pain to improve breathing and treat the respiratory infection. The physician’s discharge diagnosis was acute chest syndrome due to the sickle-cell crisis.


Principal diagnosis __________________


19. A 10-year-old male was treated in the allergist’s office for childhood asthma. He was treated for his allergies rhinitis due to pollen and animal dander with his asthma. The patient’s condition were well controlled with his current medications.


First-listed diagnosis _______________


20. A 35-year-old female at 22 weeks of her first pregnancy underwent a one-hour glucose screening test that was found to be abnormal, with a blood sugar level reported to be over 200mg/dL. The patient was sent to the outpatient laboratory for a three-hour glucose tolerance test. The reason for the laboratory test was documented on the physician order as “rule out gestational diabetes; abnormal glucose tolerance on screening during pregnancy. ”


First- listed diagnosis ______________


Secondary diagnoses _____________, _____________

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