The patient fell off a bicycle, sustaining a bruise to her right elbow, an abrasion to her right leg, and she may have
hit her head on the street. A MRI was performed and no LOC was reported. Because of suspected concussion, the patient was admitted for
overnight observation. The concussion was ruled out, and the patient was discharged.
Final Diagnosis: Concussion ruled out.
Admit dx:
Principal dx: Principal procedure/root operation:
Secondary dx:
Secondary dx:
Patient was admitted due to chest pain. Patient is on medication for hypertension. After serial cardiac enzymes and
EKGs remained negative, the patient was discharged home.
Final Diagnosis: Noncardiac chest pain.
Admit dx:
Principal dx:Principal procedure/root operation:
Secondary dx:
Secondary dx:
Chapter 17
Patient is a 67-year-old female who presented to the ER with shortness of breath. She was in her usual state of
health until 1 week ago, when she began to have chills, fever, and a cough. Patient was admitted and started on
IV antibiotics for pneumonia. Her COPD exacerbation was treated with albuterol treatments and oxygen by nasal
cannula. Sputum cultures grew Klebsiella pneumoniae. Coumadin was continued for treatment of the patient’s
chronic atrial fibrillation.
Admit dx:
Principal dx: Principal procedure/root operation:
Secondary dx:
Secondary dx:
Patient is admitted with acute on chronic respiratory failure due to emphysema. Patient is dependent on oxygen,
and has had numerous admissions for pneumonia. Patient was treated with BIPAP for 48 hours and is a DNR/DNI.
Blood gases show evidence of respiratory acidosis. No infection is identified, and deterioration in respiratory status
is thought to be a progression of his emphysema. After a family meeting it was decided to make the patient comfort
care only, and patient is discharged to home hospice care.
Admit dx:
Principal dx:Principal procedure/root operation:
Secondary dx:
Secondary dx:
Chapter 18
A 63-year-old male is admitted with a diagnosis of an incarcerated incisional hernia. The patient has a history of
prostate cancer, prostatectomy in 2002. He is an ex-smoker but has not smoked for 25 years. An open repair of the
hernia is performed using mesh.
Admit dx:
Principal dx:Principal procedure/root operation:
Secondary dx:
Secondary dx:
A 55-year-old male presents to the ER with severe abdominal pain and a long history of alcohol abuse. Patient is
currently drinking a case of beer a day. Patient is admitted to the hospital with a diagnosis of acute pancreatitis
secondary to alcoholism. The discharge summary lists secondary diagnoses of COPD, and protein calorie
malnutrition secondary to the alcoholism.
Admit dx:
Principal dx:Principal procedure/root operation:
Secondary dx:
Secondary dx:
Chapter 19
A 33-year-old heroin addict presents with cellulitis of the right toe caused by needlesticks. The patient carries a
diagnosis of AIDS. The patient is currently homeless.
Admit dx:
Principal dx:Principal procedure/root operation:
Secondary dx:
Secondary dx:
Chapter 20
A pediatric patient was admitted with a pathologic fracture of the proximal right humerus. An x-ray
suggests that the fracture was caused by a unicameral bone cyst. An orthopedic consult was obtained to see whether
this should be treated surgically. It was decided to treat conservatively and monitor healing with serial x-rays.
Final Diagnosis: Unicameral bone cyst proximal right humerus with pathologic fracture.
Admit dx:
Principal dx:Principal procedure/root operation:
Secondary dx:
Secondary dx:
The patient was admitted with disc herniation at L4-5. The patient has failed conservative treatments such as
physical therapy. NSAIDs and even steroid injections did not provide much relief. The patient was taken to surgery,
and a partial discectomy was performed. The patient recovered uneventfully and was discharged. Instructions were given
to avoid lifting anything over 10 pounds until after the postoperative clinic visit.
Admit dx:
Principal dx:Principal procedure/root operation:
Secondary dx:
Secondary dx:
Chapter 22
A patient with known breech presentation presents to the hospital in labor at 40 weeks. After an attempt at manual
rotation is made, the patient is taken to the delivery room for a low transverse C-section. She delivers a healthy
baby boy. While in the OR for the C-section, the obstetrician performs a bilateral tubal ligation.
Admit dx:
Principal dx:Principal procedure/root operation:
Secondary dx:
Secondary dx:
