CASE STUDY A 36-year-old man was admitted to the hospital after presenting at the emergency department with a self-reported, 7-month history of numbness and weakness in his right leg. He had lost 25 lb in body weight, was experiencing fecal incontinence, and had been unable to urinate for 3 days. Two years previously, the patient had been diagnosed with human immunodeficiency virus (HIV) infection. A physical examination demonstrated bilateral lower extremity weakness, and his reflexes were slowed throughout his body. Kaposi sarcoma (KS) lesions were noted, especially on the lower extremities, along with thrush and herpes lesions in the perianal region. The patient had no fever, and magnetic resonance imaging (MRI) ruled out spinal cord compression. The patient had a history of intravenous (IV) drug abuse, chronic diarrhea for 1.5 years, KS for 2 years, and pancytopenia for several weeks. The patient had large right arachnoid cysts of congenital origin. No previous laboratory reports indicated infectious agents in cerebrospinal fluid (CSF). Meningitis was suspected, and the patient was admitted with a diagnosis of polyradiculopathy (neuropathy of the spinal nerve roots) secondary to acquired immunodeficiency syndrome (AIDS). Blood and CSF specimens were collected. Although numerous white blood cells (WBCs) were found, CSF produced no growth on routine bacteriologic culture. The blood cultures were also negative. Acyclovir was administered after culture results were received. QUESTIONS: 1. How does the patient's medical history relate to his current symptoms? 2. Which opportunistic infections or conditions are used as indicators of acquired immunodeficiency syndrome (AIDS)? 3. Which immunologic markers are used to diagnose human immunodeficiency virus (HIV) infection? 4. What information provided helps determine the most likely cause of the patient's symptoms? 5. What is the causative agent of the viral disease described in the case study?

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Chapter6: Icd-10-cm Coding
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CASE STUDY
A 36-year-old man was admitted to the hospital after presenting at the emergency department
with a self-reported, 7-month history of numbness and weakness in his right leg. He had lost 25 lb in body
weight, was experiencing fecal incontinence, and had been unable to urinate for 3 days. Two years
previously, the patient had been diagnosed with human immunodeficiency virus (HIV) infection. A physical
examination demonstrated bilateral lower extremity weakness, and his reflexes were slowed throughout
his body. Kaposi sarcoma (KS) lesions were noted, especially on the lower extremities, along with thrush
and herpes lesions in the perianal region. The patient had no fever, and magnetic resonance imaging (MRI)
ruled out spinal cord compression. The patient had a history of intravenous (IV) drug abuse, chronic
diarrhea for 1.5 years, KS for 2 years, and pancytopenia for several weeks. The patient had large right
arachnoid cysts of congenital origin. No previous laboratory reports indicated infectious agents in
cerebrospinal fluid (CSF). Meningitis was suspected, and the patient was admitted with a diagnosis of
polyradiculopathy (neuropathy of the spinal nerve roots) secondary to acquired immunodeficiency
syndrome (AIDS). Blood and CSF specimens were collected. Although numerous white blood cells (WBCs)
were found, CSF produced no growth on routine bacteriologic culture. The blood cultures were also
negative. Acyclovir was administered after culture results were received.
QUESTIONS:
1.
How does the patient's medical history relate to his current symptoms?
2. Which opportunistic infections or conditions are used as indicators of acquired immunodeficiency
syndrome (AIDS)?
3. Which immunologic markers are used to diagnose human immunodeficiency virus (HIV)
infection?
4. What information provided helps determine the most likely cause of the patient's symptoms?
5. What is the causative agent of the viral disease described in the case study?
Transcribed Image Text:CASE STUDY A 36-year-old man was admitted to the hospital after presenting at the emergency department with a self-reported, 7-month history of numbness and weakness in his right leg. He had lost 25 lb in body weight, was experiencing fecal incontinence, and had been unable to urinate for 3 days. Two years previously, the patient had been diagnosed with human immunodeficiency virus (HIV) infection. A physical examination demonstrated bilateral lower extremity weakness, and his reflexes were slowed throughout his body. Kaposi sarcoma (KS) lesions were noted, especially on the lower extremities, along with thrush and herpes lesions in the perianal region. The patient had no fever, and magnetic resonance imaging (MRI) ruled out spinal cord compression. The patient had a history of intravenous (IV) drug abuse, chronic diarrhea for 1.5 years, KS for 2 years, and pancytopenia for several weeks. The patient had large right arachnoid cysts of congenital origin. No previous laboratory reports indicated infectious agents in cerebrospinal fluid (CSF). Meningitis was suspected, and the patient was admitted with a diagnosis of polyradiculopathy (neuropathy of the spinal nerve roots) secondary to acquired immunodeficiency syndrome (AIDS). Blood and CSF specimens were collected. Although numerous white blood cells (WBCs) were found, CSF produced no growth on routine bacteriologic culture. The blood cultures were also negative. Acyclovir was administered after culture results were received. QUESTIONS: 1. How does the patient's medical history relate to his current symptoms? 2. Which opportunistic infections or conditions are used as indicators of acquired immunodeficiency syndrome (AIDS)? 3. Which immunologic markers are used to diagnose human immunodeficiency virus (HIV) infection? 4. What information provided helps determine the most likely cause of the patient's symptoms? 5. What is the causative agent of the viral disease described in the case study?
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