Exam 8: Symptoms, Signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

What is meant by screening examination or test?

Name one problem that can result from lack of documentation.

Patient is admitted to the hospital with the "worst headache" he has ever had.Workup for aneurysm is performed.There is a strong family history of stroke.No cause for the headache is determined: __________

A 6-month-old infant was admitted with a febrile seizure.The patient had a temperature of 103°F and had been started on antibiotics the day before for an acute bilateral otitis media.The patient was discharged to the care of the parents on the following day.Final Diagnosis: Febrile seizure;fever due to acute bilateral otitis media.

Match the following terms to the correct definition. -Vaccination

The infant was seen in the ER for fever.Physician documented fever due to vaccination.

The patient was admitted for a takedown of colostomy.The patient underwent a colostomy 3 months ago after colon resection was performed for perforated diverticulitis.The patient was taken to the OR for open colostomy reversal with end-to-end anastomosis.The patient still has a few diverticula of the large intestine and should follow a diverticulosis diet.Final Diagnosis: Diverticulosis.Procedure: Colostomy takedown.

Patient is admitted for workup of normal pressure hydrocephalus because of ataxic gait.NPH is ruled out,and patient is discharged home: __________

Exposure to syphilis: __________

The patient was admitted for biopsy of an enlarged lymph node in the area of the left axilla.The patient has a past medical history of breast cancer with a mastectomy of the left breast 1 year ago.The patient is no longer receiving any therapy for her cancer.A needle biopsy was done.The pathology report showed normal lymphatic tissue with no evidence of metastatic spread.Final Diagnosis: Lymphadenopathy left axilla;metastasis ruled out.Procedure: Needle core biopsy axillary lymph node.

Screening for sickle cell disorder: __________

A Z code for long-term use of antibiotics should not be assigned when antibiotics are taken for a short period of time for an acute illness.

Urinary hesitancy due to enlarged prostate: __________

Signs and symptoms are not often correlated with a definitive diagnosis in the health record.

Screening for osteoporosis: __________

Urethral discharge: __________

The patient was admitted from her primary care physician's office for palpitations.The patient has never had an episode like this.The patient does have a family history of coronary artery disease.The patient was monitored by telemetry,but no specific cardiac arrhythmias were identified.The patient was instructed to return for follow-up if palpitations recurred.Final Diagnosis: Palpitations;cardiac arrhythmia ruled out;family history of coronary artery disease.

Match the following terms to the correct definition. -Objective evidence of a disease or of a patient's condition as perceived by the patient's examining physician

Counseling on the initiation of contraceptive foam use: __________

Which of the following is NOT true of status codes?