Exam 9: Symptoms, signs, and Abnormal Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes

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.

MATCHING 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

Another name for the coma scale is ______________ coma score.

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.

Oral phase dysphagia: __________

Retained metal fragment: __________

On physical exam the physician noted that the patient had hepatosplenomegaly.Further testing was ordered and the patient will return in 2 weeks.

Patient has a cystostomy: __________

Screening for osteoporosis: __________

Positive Mantoux test: __________

What is meant by screening examination or test?

Patient was seen in the clinic.Final diagnosis is RUQ rebound abdominal tenderness.

A(n)____ code is used to explain continuing surveillance following completed treatment of a disease,condition,or injury.

A 6-month-old infant was admitted with a febrile seizure.The patient had a temperature of 103°F.The patient was discharged to the care of the parents on the following day. Final Diagnosis: Febrile seizure.

The patient was admitted with abdominal pain in the right upper quadrant.Workup included an EGD that showed some mild gastritis,and abdominal ultrasound was positive for gallstones in the gallbladder. Final Diagnosis: Abdominal pain due to gastritis versus cholelithiasis. Procedure: Esophagogastroduodenoscopy with biopsy of the stomach.

List one reason why a screening code would not be necessary.

The patient is admitted to the hospital with fever and dehydration resulting from pneumonia.