Module 3 Case Studies
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Fayetteville Technical Community College *
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Course
249
Subject
Medicine
Date
Apr 3, 2024
Type
docx
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8
Uploaded by LCampbell1918
CARROLTON DIGESTIVE MEDICINE, PA
765 SWOLLOW PATH • PASSING, FL 32811 • 407-555-7985
PATIENT:
Friedman, Doris
ACCOUNT/EHR #:
FRIEDO001
Procedure Performed:
Colonoscopy
Physician:
Matthew Appellet, MD
Indications:
History of inflammatory bowel disease
Procedure:
The patient was given no premedication at her request and the Olympus PCF-130 colonoscope was used. The mucosa of the rectum was essentially normal apart from some mild, nonspecific edema. Photographs and biopsies were obtained. The remainder of the rectum was normal. The sigmoid was normal, as was the descending colon, splenic flexure, transverse
colon, hepatic flexure, right colon, and cecum. No evidence of polyps, tumors, masses, or inflammation. The scope was then withdrawn, these findings confirmed. The procedure was terminated and the patient tolerated it well.
Impression:
Normal colonic mucosa through the cecum
Plan:
Await results of rectal biopsies
Matthew Appellet, MD
Feedback:
Z87.19: ICD-10-CM index>history>personal>disease or disorder>digestive system>specified
condition NEC
45380: CPT index>colonoscopy>flexible> biopsy
CARROLTON DIGESTIVE MEDICINE, PA
765 SWOLLOW PATH • PASSING, FL 32811 • 407-555-7985
PATIENT:
BENJAMIN, DAVIDA
ACCOUNT/EHR #:
BENJDA001
S:
Pt is a 49-year-old female complaining of abdominal pain. She states that the pain has been consistent since noon, and she has been vomiting since 2 p.m. She has been experiencing chills and weakness as well. No diarrhea. Last BM was a small one at 7 a.m. and again at 2 p.m. She was in good health prior to the symptoms at noon. She also has GERD.
Patient had a total hysterectomy 3 years ago and a laparoscopic cholecystectomy 10 years ago. She quit smoking 10 years ago. Current meds:
Evista, Prevacid prn.
O:
Weight 140 Height 5 feet 2 inches T 99 P 90 R 18 BP 128/73. Abdomen distended, tympanic, tender. CT scan abd/ pelvis: Dilated small bowel loop appears to contain semisolid material in RLQ, compatible with early small
bowel obstruction. EKG: sinus tachycardia, otherwise normal EKG. Bowel sounds are normal and hypoactive. Breathing pattern is nonlabored, breath sounds clear. Heart rhythm: regular. Neck veins: nondistended. Skin: warm, dry, intact. Peripheral pulses: normal. CBC w/differential: WBC, RBC, HGB, and HCT are high; MCHC is low; all other results unremarkable. Glucose and BUN/Creat are high, anion gap is low, all other chemistry unremarkable. UA: UR is cloudy, glucose high.
A:
Small bowel obstruction; pure hypercholesterolemia; diaphragmatic hernia with obstruction; esophageal reflux with esophagitis
P:
Admit to hospital for surgery
Suzanne R. Taylor, MD
Feedback:
K56.600: ICD-10-CM index>obstruction>intestine>partial
E78.00: ICD-10-CM index>hypercholesterolemia
K44.0: ICD-10-CM index>hernia>diaphragm>with>obstruction
K21.00: ICD-10-CM index>reflux>esophageal>with esophagitis
99223-57: CPT index>evaluation and management>hospital
74176: CPT index>CT scan>without contrast>abdomen
93000: CPT index>Electrocardiography>evaluation
85025: CPT index>blood cell count>complete
82947: CPT index>glucose>blood test
84520: CPT index>blood urea nitrogen
81000: CPT index>urinalysis
ADULT HEALTH ASSOCIATES
720 LONG STREET • ETERNITY, FL 32711 • 407-555-7322
PATIENT:
ANDERSON, LAWRENCE
ACCOUNT/EHR #:
ANDELA001
This 89-year-old male was seen in his room at the Sun City Nursing Home for his regular annual checkup. Pt is stable and doing well on his current regime of medications. PE shows age-appropriate condition. HEENT unremarkable. Coordination with resident medical director to review and affirm medical plan of care.
James Healer, MD
Feedback:
Z00.00: ICD-10-CM index>examination>medical (adult)
99397: CPT index>evaluation and management>preventive medicine>established patient>65 years and older
ADULT HEALTH ASSOCIATES
720 LONG STREET • ETERNITY, FL 32711 • 407-555-7322
PATIENT:
CARR, FAITH
ACCOUNT/EHR #:
CARRFA001
This is a 79-year-old Native American female who lives in a very rural area about 30 miles outside the city. Her home is a crowded two-bedroom cottage in which three of her five children and six of her grandchildren reside. She does not speak or understand English very well and requires a translator when meeting with health care professionals. Her youngest daughter, Lantana, came to interpret for her today.
HPI:
She has come to the office today because she is experiencing shortness of breath, upper bilateral chest pain, and difficulty swallowing solids and semisolids (but not liquids).
EXAM:
T 101.5F, R 15, Height 5 feet 1 inch, Weight 180 lb. HEENT: Head—
unremarkable; eyes—PERRLA; ears—unremarkable; nasal passages appear to be clear; throat—mucosa appears erythematic, and there are indications of edema. Chest sounds are raspy and difficult.
LAB/RADIOLOGY:
Sputum cytology, saccomanno technique; CBC w/differential; chest x-ray, frontal view; swallowing assessment, and laryngoscopy are performed during this visit.
DX:
Advanced cancerous lesions in both lungs with metastasis to her larynx
TX:
Patient is admitted to the hospital for an emergency total laryngectomy because her airway system was being compromised by the laryngeal tumor.
Patient, along with her daughter, was seen by the consulting ENT, Dr. Fallana, and speech-language pathologist (SLP), Roxan Kinney pre- and postoperatively.
Roxan Kinney, SLP, counseled the patient, via interpretation by her daughter, regarding the use and care of an electrolarynx (Servox brand). Written instructions (in English) were given to the daughter regarding the use and
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care of the electrolarynx, as well as a description of nonverbal communication strategies.
PLAN:
Patient to undergo a short course of chemo- and radiotherapies intended to ease her chest pain. Long-term therapies are not recommended or implemented.
Prognosis:
Poor
James Healer, MD
Feedback:
C34.91: ICD-10-CM neoplasm table>lung>malignant primary>right
C34.92: ICD-10-CM neoplasm table> lung>malignant primary>left
C78.39: ICD-10-CM neoplasm table>larynx>malignant secondary
99223-57: CPT index>evaluation and management>hospital services>Inpatient or Observation care>initial
71045: CPT index>x-ray>chest
85025: CPT index>blood cell count>complete (CBC)
88108: CPT index>Saccomanno Technique
31360: CPT index>laryngectomy>total
92607: CPT index>speech evaluation>for prosthesis
PEDIATRIC COMPLETE CARE CENTER
123 BORNE PATH • YOUNGSTOWN, FL 32811 • 407-555-ABCD
PATIENT:
THORNSON, BRITTA
ACCOUNT/EHR #:
THORBR001
Procedure Performed: Newborn Evaluation
The patient is a female, gestational age 37 weeks, 4 days, born vaginally in this facility, two days ago, 04:15.
IMPRESSION:
Neonate was of a single birth, BWT 2,857 grams without significant OR procedures with a normal newborn diagnosis. 18.5 inch long. Head circumference: 33 cm. Amniotic fluid: clear, Cord: 3 vessels. Evidence of a benign tumor of blood vessels due to malformed angioblastic tissues
(vascular hamartomas) at right groin. Appears pale, has poor skin turgor, is mucousy, and has transitional stool.
APGAR SCORE:
1 minute = 9; 5 minutes = 9. Heart rate: >100; respiratory effort: good; muscle tone: active; response to catheter in nostril: cough; color: body pink, extremities blue
MATERNAL HISTORY:
29 years old, G1, blood type O+, spontaneous labor, 16 hour, 24 minutes, epidural anesthesia, HIV-tested during pregnancy:
neg
ADMINISTRATIONS:
Hepatitis B, peds, vaccine (recomb) 5 mcg/0.5 mL, given: 09/03/18
NEWBORN HEARING SCREENING:
Passed
RECOMMENDATIONS:
Follow-up in office 2 days
Pravdah H. Jeppard, MD
Feedback:
Z38.00: ICD-10-CM index>newborn>born in hospital
D21.5: ICD-10-CM neoplasm table>connective tissue>groin>benign
99460: CPT index>evaluation and management>newborn care
PEDIATRIC COMPLETE CARE CENTER
123 BORNE PATH • YOUNGSTOWN, FL 32811 • 407-555-ABCD
PATIENT:
GEMISONN, PHILLIP
ACCOUNT/EHR #:
GEMIPH001
S:
Pt is a 3-day-old male who comes in for his first office visit. I first saw Phillip in the hospital after delivery. He was a full-term infant, vaginally delivered. Mother provides prenatal history and family history, including the paternal Rh factor and information regarding inherited red cell defects.
O:
Weight 6 lb. 3 ounces, T 98.6. Skin has yellowish skin coloration, including
sclerae. Tests, including direct and indirect bilirubin levels, reveal Gram-
negative bacterial infection and serum bilirubin levels at 7 mg/ dL. Blood tests are also performed to test infant and mother both for blood group incompatibilities, hemoglobin level, direct Coombs’ test, and hematocrit.
A:
Hyperbilirubinemia, due to Gram-negative bacterial infection
P:
1. Rx: Albumin administration (1.0 g/kg of 25% salt-poor albumin)
2. Rx: Antibiotics for infection
3. Follow-up appointment in 4 days
Pravdah H. Jeppard, MD
Feedback:
P59.8: ICD-10-CM index>newborn>jaundice>due to>specified NEC
B96.89: ICD-10-CM index>infection>bacterial>as cause of disease classified elsewhere
99213: CPT index>evaluation and management>office and other outpatient services>established patient
82247: CPT index>bilirubin>blood
86920: CPT index>compatibility test>blood
85018: CPT index>blood cell count>hemoglobin
85014: CPT index>blood cell count>hematocrit
86880: CPT index>Coombs test>Direct
FRAISER, HARROLD & YAWZI, Neurology
81 BAYER BOULEVARD • SENSATION, FL 32811 • 407-555-5852
PATIENT:
SAMI, KAREN
ACCOUNT/EHR #:
SAMIKA001
The patient is a 29-year-old female with a history of recurrent sinus infections who was well until 6 days ago. She presents with fever, severe frontal headache, facial pain, and runny nose. Patient states she has been having difficulty concentrating. I last saw this patient 6 months ago for sinusitis.
Weight 145 lb. B/P 120/85 T 101.5°
HEENT:
Tenderness over frontal and left maxillary sinuses. Nasal congestions visible.
CT scan reveals opacification of both frontal and left maxillary, sphenoid sinuses and a possible large nonenhanced lesion in the brain.
Parasagittal MRI and axial MRI show a large (7 cm), well-circumscribed epidural collection compressing the left frontal lobe.
DX:
Epidural abscess with frontal lobe lesions caused by significant compression on frontal lobe
Recommendation for surgery to evacuate the abscess
RX:
Antibiotics and pseudoephedrine
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Suzanne R. Taylor, MD
Feedback:
G06.0: ICD-10-CM index>abscess>epidural>brain
G93.5: ICD-10-CM index>compression>brain
99213: CPT index>evaluation and management>office and other outpatient services> established patient
70486: CPT index>CT scan>without contrast>face
70551: CPT index>magnetic resonance imaging>brain
FRAISER, HARROLD & YAWZI, Neurology
81 BAYER BOULEVARD • SENSATION, FL 32811 • 407-555-5852
PATIENT:
JOHNSON, KELVIN
ADMISSION DATE
: 11/09/23
HPI:
This 33 year old male patient was recently in the hospital. He was diagnosed with a malignancy. Patient has been undergoing outpatient radiation. His son called me and stated the patient was having some difficulty breathing and his mental status seemed to have deteriorated in a rather rapid nature. I discussed this with the nurse at the extended care facility where he resides, and we gave him a Lasix IM 40 mg. He did not respond very much, and they brought him to the emergency room (ER). Initial tests were negative, but after discussion with his internist, it was decided to go ahead and admit patient for further neurologic evaluation.
PMH:
Significant for the malignancy, cerebral hypertension, gastritis, diabetes, secondary to steroids. He also has osteoarthritis.
MEDICATIONS:
Patient has been maintained on Prevacid 30 mg po bid, Bumex 0.5 mg po q day prn, Captopril 100 mg q 12, Norvasc 10 mg po q day, insulin sliding scale. Decadron per the radiation/oncologist. Depakote 250 mg qid and Diflucan recently 150 mg po q day. Phenergan on prn basis for nausea, Tylenol grains 10 q 4-6 prn pain, Darvocet one q 4-6 prn pain. Chloraseptic spray to the mouth. His diet is thick and liquid as tolerated, diabetic diet.
SOCIAL HISTORY:
Noncontributory at this time.
FAMILY HISTORY:
Noncontributory at this time.
VITAL SIGNS:
Stable
GENERAL APPEARANCE:
Somewhat lethargic-appearing white male, he has always been somewhat quiet with a flat affect.
HEENT:
Normal
CERVICAL AND CARDIOPULMONARY EXAM:
Unchanged
LUNGS:
Clear
HEART:
Heart rate regular
ABDOMEN:
No obvious pain, normal bowel sounds
EXTREMITIES
: Trace edema bilaterally
IMPRESSION:
The patient is admitted with a known brain tumor, currently undergoing radiation, He is admitted today by the neurologist for evaluation regarding his mental changes.
Feedback:
C71.0: ICD-10-CM neoplasm table>brain>cerebrum>malignant, primary
R41.82: ICD-10-CM index>change>mental status
99223: CPT index>evaluation and management>hospital services>Inpatient or Observation care>initial