1. This 25 year old patient was admitted with diffuculty breathing. She has AIDS and is in the 21st week of pregnancy. Workup shows Pneumocytitis Carinii pnuemonia. What are the dx codes to be assigned for this case?
2. This 35 year old female patient has carcinoma of the upper-outer breast. She had a lumpectomy performed and a sentinel node biopsy of the axillary lymph node. The pathology report for the lymph node states no pathology change. What diagnosis and procedure codes would you report?
3. The discharge dx for the pt is UTI with sepsis due to streptococcus. Urine culture and blood cultures were positive for streptococcus. After query to the physician regarding the meaning of sepsis, an addendum was added to the record with the dx of sepsis with streptococcal septiceima and UTI due to sterptococcus B. What diagnosis codes are assigned?
The following information was contained in the health record:
4. Chief Complaint: History of nausea with severe vomiting for the past 2 to 3 days. Type I diabetes mellitus because the pt was 12 years old at the time of onset.
Hospital Course: This 31 year old male patient has a history of Type I diabetes mellitus and is on 15 units NPH and 10 of regular in the morning and 10 units of NPH and 5 regular in the evening . The patient started having symptoms of nausea. The pt at the same time had increased frequency of urination and polydipsia. The patient was dehydrated upon admission. There was not evidence of thrombophlebitis, varicosities, or edema on examination of the extremities. The pt was hydrated, and as a result, the blood sugar decreased from more than 600 to normal levels. The patient was discharged with the diagnosis of diabetic ketoacidosis, type I uncontrolled . What principal diagnosis code is assigned?
5.The pt was admitted when an MRI revealed cerebral aneurysm. After admission a cerebral angiogram was performed that showed non ruptured arteriosclerotic aneurysm to the anterior cerebral artery. An anueurysmectomy by anastamosis was performed using Martex graft replacement. What diagnosis and procedure codes are reported
6. This 65 year old male was admitted to the hospital in acute urinary retention. A laser guided transuretheral resection of the prostate was performed and the diagnosis made of benign nodular hyperplasia of the prostate. When the pathology report was reviewed, there was documentation of NPH and a microscopic foci of adenocarcinoma ( IN SITU )of the prostate, which was confirmed by the physician. What diagnosis and procedure codes are reported
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