HIT 201 Coding Cases – Workbook – Flashcards

Case Scenario 1, page 72: A 61-year-old male patient is admitted with the chief complaint of shortness of breath on minimal exertion & chest discomfort. The patient has a personal history of lung infections & smoking for a long period of time. The patient has a family history of diabetes & hypertension. Physical examination reveals rhonchi. Blood pressure is 110/75. During hospitalization, the patient undergoes lab workup, chest X-ray, & chest CT scan. A right upper lobe lesion is noted on chest CT scan. A bronchoscopy with biopsy is performed & the pathology report identified non-small cell lung carcinoma. Diagnosis & treatment options are discussed with the patient. The patient is discharged & scheduled for chemotherapy. PROCEDURE: Bronchoscopy of right lung, via artificial opening, with biopsy of upper lobe of the right lung. FINAL DIAGNOSIS: Non-small cell carcinoma of the right upper lobe, primary site.

Case Scenario 1, page 77: Patient admitted because of pain in his back & low-grade fever with chills. He gave a history of having had malaria while overseas several years ago. Physical examination was essentially negative except for a slightly elevated temperature. Chest X-ray was normal. Urinalysis was essentially normal, as was the complete blood count. Throat culture revealed hemolytic Streptococcus in spite of normal appearance of throat. Urine culture negative. Reports have not been received on agglutination tests. Patient was treated initially with Pyrilgin, Darvon & Loridine injections. He was later given a course of Aralen & Primaquine. He was also put on Terramycin because the throat culture showed presence of Streptococcus. He felt better the 2nd day but then felt worse with fever & pain on the 3rd day. This was when it was decided to give him the Aralen & Primaquine. He has been afebrile & feeling much better for the past 2 days. Patient is discharged to continue 11 more days with Primaquine, which will be equivalent to 14 full days of therapy. He is also to take Mycebrin-T once daily. FINAL DIAGNOSIS: Probable exacerbation of malaria. Strep throat.

Case Scenario 2, page 73: Full-term female born via vaginal delivery on 05/04/YYYY to a 27-year-old in the hospital. Estimated gestational age, 40 weeks. Mother had two pre-natal visits. Rupture of membranes was clear fluids. Delivery was uncomplicated, & APGARS were 9/9. Examination of single live-born revealed birth weight of 3535 grams, head circumference 35 centimeters, length 53.5 centimeters, & extra digits on all 4 extremities. Infant admitted to nursery for routine care & feeding. X-rays of both hands & feet & surgical consultation ordered. X-rays of all extremities revealed that this newborn has no bony involvement in the extra digits. Surgical consultation was requested for evaluation of the infant's feet. The mother consented to the procedure of having the extra digits of the newborn's hands tied off. This was done on 05/05/YYYY. The baby was discharged with her mother on 05/06/YYYY with a follow-up appointment for post-surgical evaluation of the feet. PROCEDURE: Ligation of extra digits, both hands & both feet FINAL DIAGNOSIS: Stable, full-term female infant. Polydactyly of fingers & toes, both hands & feet.

Case Scenario 2, page 78: Patient admitted with night sweats, fever, headache, poor appetite, dizziness & weakness. Height 5'6" & weight 164 pounds. Past medical history reveals obesity, hyperopia, astigmatism, presbyopia with decrease in field of vision of left eye inferiorally, visual & hearing deficiencies, & benign prostatic hypertrophy. Physical exam reveals membrana typmanica slightly scarred & dull. Teeth in poor repair. Tonsils tiny. Atrophic right teste. Crepitation on motion with pain & restriction of motion in knees. Lab results showed increased antibody titer of tularemia; dilutions of 1:160 up to 1:1280 in a period of about one week. Erythrocyte sedimentation rate elevated to 31 mm per one hour. Alkaline phosphatase 7.4 (normal is 7.0). All other laboratory tests were normal. Chest x-ray, PA & lateral views, were negative except for a small amount of arteriosclerotic changes in the aorta. Patient received intravenous fluids with intravenous Terramycin, Sumycin, & Fiorinal with codeine. Patient's condition has shown satisfactory improvement during hospitalization. Discharged home. FINAL DIAGNOSIS: Tularemia

Case Scenario 3, page 73: A 78-year-old female was admitted on 01/27/YYYY for progressive exertional shortness of breath & leg edema. The patient has a history of hypetension & non-obstructive hypertrophic cardiomyopathy. On admission, she was in mild respiratory distress. She had distended neck veins. Her heart was irregular with systolic murmur at the apex. Her lungs were clear; however, she had 3 plus hepatomegaly, which was tender. She had 3 plus leg edema. Her chest X-ray showed cardiomegaly with pulmonary vascular congestion. Her laboratory studies were essentially unremarkable. An echocardiogram was done that showed biatrial enlargement & significant left ventricular hypertrophy. The patient was initially treated with bed rest, fluid & sodium restrictions, & intravenous Lasix. She was also started on Norpace to convert to normal sinus rhythm, which was unsuccessful. Eventually, the patient underwent cardioversion, which readily converted the patient to normal sinus rhythm; & after cardioversion, she was started on Rythmol 150 mg 3 times a day. She remained in normal sinus rhythm throughout her hospital stay. She is to be followed closely as an outpatient. PROCEDURE: Cardioversion FINAL DIAGNOSIS: Congestive heart failure. Hypertrophic cardiomyopathy. Systemic hypertension.

Case Scenario 3, page 78: This 93-year-old white female was admitted to the hospital with the chief complaint of a mass in her left breast in the upper outer quadrant. Breast examination revealed a large hard nodule with skin thickening & had the appearance of being a carcinoma. All blood work & electrolytes were within normal limits, except she did have cholesterol of 304. Urinalysis was negative & EKG was normal. Chest X-ray showed some calcification of the mitral valve & dilation of the aorta, otherwise negative. The patient was admitted to the hospital, prepared for surgery, & taken to the operating room where, under satisfactory general endotracheal anesthesia, a mass was removed from her left breast & sent for frozen section. The frozen section was positive for carcinoma; therefore, a modified radical mastectomy was done of the left side. Following the operation, she had an uncomplicated post-operative recovery. The wound is clean & healing satisfactorily, & she is afebrile & ambulatory. She is discharged home in an asymptomatic condition. PROCEDURES: Removal of breast tumor. Modified radical mastectomy, left (which includes re-section of axillary lymph nodes, left side) FINAL DIAGNOSIS: Carcinoma of the upper outer quadrant of the left breast with metastasis of 2 out of 14 axillary lymph nodes.

Case Scenario 4, page 74: A 25-year-old, HIV-positive female patient was admitted for tubal ligation. Her last menstrual period started last month (June 11). Physical exam revealed blood pressure of 132/74 & no breast masses. Cardiovascular revealed regular rate & rhythm. Lungs were clear to ausculation. Abdomen revealed positive bowel sounds & was soft & non-tender. Pelvic exam revealed vulva without lesions, white discharge & closed cervix. Uterus was normal & adnexa was without masses. The patient underwent elective sterilization procedure bilaterally with the use of Falope ring. Post-operatively, the patient was noted to have a run of bradycardia in the recovery room. She was administered intravenous medications for this & was sent to the medical floor for continued care. After 1 additional day of treatment, the patient was discharged. PROCEDURE: Female sterilization procedure Falope ring, via artificial opening, endoscopic approach. FINAL DIAGNOSIS: HIV positive. Elective sterilization. Post-operative bradycardia.

Case Scenario 4, page 78: This 62-year-old male who has undergone pre-operative chemotherapy & radiation treatment for distal rectal adenocarcinoma is now admitted for surgical treatment. The patient was taken to the operating room, where he underwent lower abdominal re-section, sigmoid coloanal anastomosis, & diverting ileostomy. Patient tolerated the procedure well. He was transferred to the surgical floor post-operatively. He continued to progress, & his ileostomy began to produce stool. His labs remained stable throughout his stay. He was tolerating a regular diet very well with good ostomy output. The incision remained clean, dry, & intact throughout his stay. Staples were left intact at discharge. Patient was discharged home with home health nursing for ileostomy care. PROCEDURES: Abdominoperianal re-section of rectum with sigmoid coloanal anastomosis & diverting ileostomy. FINAL DIAGNOSIS: Rectal carcinoma. Coronary artery disease. Gastroesophageal reflux disease.

Case Scenario 5, page 79: Female patient admitted with uncontrolled Type 2 diabetes mellitus & pain of the hands, which is of questionable etiology. Rule out vasculitis. The patient is a 64-year-old Caucasian female with history of diabetes mellitus for several years & is now Type 2. For the last several weeks, her glucose levels have been very high at 290 to 350. We increased her insulin, but she was still running quite high. She has been complaining of pain in her right hand &, to a lesser degree, her left hand. They get red, tingly, & painful; it looks as though she may have vasculitis. Blood pressure 120/64, weight 139 pounds. Patient has some funduscopic arteriosclerotic changes & has been treated for diabetic retinopathy. Lungs are clear. She has some clubbing of the fingers. No cyanosis. Tips of her fingers & thumbs on both hands look red. She is quite tender over the first metacarpal phalangeal joint of the right hand. Doesn't appear to be particularly swollen or feel hot to the touch. She is admitted for vigorous treatment & further evaluation. Urinalysis normal. Complete blood count normal. Sedimentation rate was 77. Fasting sugar on the day after admission was 230; later that day, 166. Glucose levels remained high for the next few days. Chest X-ray was normal. Hand X-rays revealed demineralization of bones but no significant arthritic changes. The patient's hospital course was one of gradual improvement. We started her on Prednisone 20 mg twice daily, maintained her usual medications, & had to increase her Insulin somewhat. The redness in her hands went away. Of course, her glucose levels remained high on the Prednisone until we got the Insulin increased enough. She had a percutaneous temporal artery biopsy, which revealed no diagnostic changes. I still believe she has both collagen vascular disease & vasculitis. She has responded to treatment. She is being discharged home. We will see her in the office in one week for follow-up, sooner if any difficulty. PROCEDURE: Left percutaneous temporal artery biopsy. FINAL DIAGNOSIS: Type 2 diabetes mellitus, uncontrolled. Probable collagen vascular disease Probable vasculitis of both hands.

Case Scenario 6, page 75: Matthew Saunders was brought to the emergency department by his parents, who stated that the 12-week-old child had been vomiting for 3 days. Physical exam revealed a listless child with sunken eyes. His abdomen was soft with normal bowel sounds. Lab workup was done, & the child was admitted as an inpatient. Intravenous fluids were immediately started because the child was severely dehydrated . Upper gastrointestinal series showed pyloric mass & narrow pyloric channel. The child was transferred to the local children's hospital for surgical treatment. FINAL DIAGNOSIS: Infantile hypertrophic pyloric stenosis. Severe dehydration.

Case Scenario 7, page 75: An 84-year-old male patient was admitted with a chief complaint of tarry & red-colored stools. The patient has a history of colon polyps, although he underwent colonoscopy about 2 years ago that showed he was free of disease. His additional past medical history includes a history of hypertension, for which he is on Lopressor 50 mg twice daily & Prinzide 10/12.5 mg once daily. He is also on Lipitor 10 mg daily for hyperlipidemia. Physical exam revealed normal color& blood pressure of 130/60 supine, dropping to about 116 systolic upon sitting up, associated with mild dizziness. He was afebrile. Regular rhythm was normal. Neck: carotid pulsations two plus bilaterally without bruits. Lung field were clear. Abdomen was not distended. Bowel sounds were normal. Rectal exam showed melanotic stool that was strongly positive for occult blood The patient was admitted for intravenous fluids. He was typed for 2 units of blood. Frequent hematocrit & hemoglobin lab tests were obtained, & frequent vital signs were taken. The patient underwent upper endoscopic study. Lab results revealed white blood cell count of 7,000. Hemoglobin 12.1 with hematocrit of 33.6 & a normal platelet count. Blood urea nitrogen was 38 & creatinine 1.1, probably reflective of blood in the gut. During hospital course, the patient's hemoglobin gradually dropped to the range of 9.9 to 10.4. Oral medications for hypertension & hyperlipidemia were continued. An esophagogastroduodenoscopy was done, which revealed a prepyloric ulcer. There was some bleeding noted in the are surrounding this ulcer. The patient was stable after the procedure. Discharge medications: Prilosec 20 mg once a day; Feosol 325 mg 3 times each day, after meals; Prinzide 10/12.5 mg daily, & Lipitor 10 mg once a day. PROCEDURE: Esophagogastroduodenoscopy. FINAL DIAGNOSIS: Prepyloric peptic ulcer with acute hemorrhage. Hypertension. Hyperlipidemia.

Case Scenario 7, page 80: The patient was admitted through the emergency room following an acute hemorrhage in an area of oral surgery & multiple extractions. The patient presented with profuse bleeding, stating that the area suddenly started bleeding approximately 2 to 3 hours prior. She had had all sutures removed two days ago from an area of multiple extractions in the mandible & had no incidence until now. Patient has a history of idiopathic thrombocytopenic purpura, & it is likely that the bleeding was a result of this syndrome; however, her prothrombin times were normal. Complete blood count was normal. The patient's mouth was re-sutured in the emergency room, & she was admitted to the hospital for overnight observation. She did very well & did not re-bleed at all. She was discharged home with a follow-up appointment. PROCEDURE: Suture repair, external buccal mucosa (mouth). FINAL DIAGNOSIS: Acute hemorrhage. Idiopathic thrombocytopenic purpura.

Case Scenario 8, page 76: A 68-year-old male was admitted for elective cystectomy due to bladder carcinoma. The patient has a medical history of hypertension & glaucoma. While hospitalized, oral anti-hypertensive & ocular medications were continued. The patient underwent partial cystectomy via open approach with enterocystoplasty, using part of the sigmoid colon. (Sigmoid colon was excised using open approach). Post-operative diagnosis was malignant neoplasm of trigone of the bladder. Post-operatively, the patient did well until the third post-operative day, when his creatinine & blood urea nitrogen (BUN) were 2.4 & 35 milligrams, respectively. The patient was in acute renal failure. Medications were administered, which brought his creatinine down to 1.7 & his BUN down to 29 milligrams. The patient was discharged on the 7th day after surgery with home health care ordered. He will be monitored closely. PROCEDURE: Partial cystectomy with enterocystoplasty, using part of the sigmoid colon. FINAL DIAGNOSIS: Carcinoma, bladder. Hypertension. Glaucoma. Post-operative acute renal failure.

Case Scenario 8, page 80: Patient admitted to the hospital from the emergency room with history of having taken several tranquilizer or nerve-type tablets. She was groggy & sleepy upon arrival. Patient states that she was not trying to hurt herself but that she just "wanted to calm down". Examination revealed a well-developed 43-year-old white woman who appeared to be very groggy, but she was aroused with very little difficulty. Complete blood count was normal. Potassium was a little low at 3.7. Other electrolytes were normal. Fasting blood sugar & blood urea nitrogen were normal. Patient had nasogastric tube passed & was given intravenous Lactated Ringers. Later, after she became more alert, Valium 5 three times per day. The nasogastric tube was removed after a few hours. The patient was allowed to be up. She has been sleeping most of the time on the sedatives given. Patient was discharged home. She will be followed as an outpatient. FINAL DIAGNOSIS: Accidental overdose of tranquilizer. Acute anxiety state. (Initial encounter)

Case Scenario 9, page 76: A 30-year-old male is admitted with right lower quadrant (RLQ) abdominal pain. The patient also complains of loss of appetite & nausea. Pain is noted by patient to be 7 out of 10. Exam reveals hypoactive bowel sounds, tenderness & guarding in the RLQ. The patient is admitted with the diagnosis of rule out appendicitis. Lab work shows white blood cell count of 12.0, & complete blood count is within normal limits. The patient consents to an exploratory laparotomy, which revealed a normal appendix & Meckel's diverticulum. Laparotomy incision was extended & appendix & a segment of the patient's ileum are re-sected during the procedure. PROCEDURE: Exploratory laparotomy with open re-section of appendix & excision of a segment of ileum. FINAL DIAGNOSIS: Meckel's diverticulum

Case Scenario 10, page 77: A 2-day-old male infant is admitted to the local Children's Hospital for cleft lip repair. Baby Boy Mitchell was born the previous day at a local community hospital. He has a complete cleft lip on the left side. On the 3rd day of admission to Children's Hospital, pre-operative lab results reveal a blood glucose level of less than 40 after a feeding. The baby is observed & scheduled surgery for repair of the cleft lip is rescheduled. A fasting blood glucose done after 12 hours reveals a level of 30. The baby receives subcutaneous injections of glucagon for hypoglycemia & is evaluated for possible insulinoma. After diagnostic testing, insulinoma is ruled out. The baby is monitored for 72 hours in the neonatal intensive care unit. After blood glucose is normal per lab results, the cleft lip repair is done. The infant is discharged home for close follow-up with his pediatrician to monitor the hypoglycemia. PROCEDURE: Repair, cleft lip (upper lip) FINAL DIAGNOSIS: Complete cleft lip, left side. Neonatal hypoglycemia.

Case Scenario 11, page 81: Patient is a 76-year-old female with prior history of cerebrovascular accident, suffered on the left side without any residual initially. The patient was treated for this 4 weeks ago & discharged. She has previous subendocardial infarction & Type 2 diabetes mellitus controlled with diet. Patient also has mild Parkinson's disease, which is controlled with Sinemet. Patient is re-admitted with dense non-dominant side right hemiplegia with aphasia. (Patient identified as left-handed). While hospitalized, her medications for atherosclerotic cardiovascular disease & Parkinson's were continued, & she was placed on a diabetic diet. Flaccid paralysis continued, but she did start to develop some finger & arm motion & minimal leg motion before discharge. She also showed further improvement regarding use of the right arm & foot. We considered the need for rehabilitation, & she is being transferred to the rehabilitation hospital for further treatment. FINAL DIAGNOSIS: Status post left hemisphere cerebrovascular accident. Dense right non-dominant side hemiplegia with aphasia. Atherosclerotic cardiovascular disease of native coronary arteries. Previous subendocardial myocardial infarction. Type 2 Diabetes Mellitus. Parkinson's Disease.

Case Scenario 12, page 82: Patient is admitted with acute ST elevation (STEMI) anteroseptal myocardial infarction. This 62-year-old man stopped his Procardia one month ago & had an onset of pericardial pressure going up his neck & down the inside of both arms at 10:30 this evening. This lasted for approximately one hour. He was brought to the emergency room where, upon EKG, he was found to be having an acute ST elevation (STEMI) anteroseptal myocardial infarction. Chest X-ray showed chronic obstructive pulmonary disease. Upon admission, creatine kinase (CK) isoenzymes were 89; later that evening total CK was 1680. The following day, CK was 1170. Urinalysis was normal. Electrolytes & complete blood count were normal. Arterial blood gas on 4 liters revealed PO2 of 73, PCO2 of 40, pH of 7.43. On the day of discharge, PO2 on room air was 67. In the intensive care unit, his Procardia was re-started, & Lidocaine drip was begun. Lasix was also added to his IV. He had no further angina. His lungs remained clear, & telemetry showed normal sinus rhythm. After 48 hours, the Lidocaine was weaned, the patient suffered no arrhythmias, & he was moved to the floor. He was able to walk in his room without angina. He remained out of failure & free of angina or arrhythmia. FINAL DIAGNOSIS: Acute ST elevation (STEMI) anteroseptal myocardial infarction. Chronic obstructive airway disease. Arteriosclerotic cardiovascular disease with angina pectoris. Status post myocardial infarction in 1977.

Case Scenario 15, page 83: A severely dehydrated 91-year-old woman was admitted to the hospital with respiratory rate of 40. She complained of shortness of breath, & peripheral cyanosis & hypotension were noted. Medications included Lasix & potassium supplementation. In the emergency room she had an orthostatic fall in her blood pressure. EKG was normal. Chest X-ray showed normal heart size with atelectasis at the left base. Lung scan was normal. Arterial blood gases on room air showed a PO2 of 43, PCO2 of 25, & a pH of 7.57 (normal range PO2 of 95-100; PCO2 35 to 42; & pH 22 to 26). On 6 litersof oxygen, her PO2 rose to 73. The patient was admitted to the intensive care unit, & routine orders were followed. Her Lasix was held, as well as her potassium supplementation. IV fluids were given for hypotension & dehydration. Medications for coronary atherosclerosis were administered. After several days of treatment, she was discharged to a skilled nursing facility with portable oxygen. Her PO2 at discharge was 85. FINAL DIAGNOSIS: Acute respiratory failure, questionable etiology, with hypoxia. Dehydration. Coronary atherosclerosis of native arteries.

Case Scenario 16, page 83: An 84-year-old white female admitted with dehydration, malnutrition, & late stage Alzheimer disease. The patient is not on medication for Alzheimer. She has had poor to no oral intake over the last several days, & her urine output within the last 15 hours prior to admission was 200 cubic centimeters. She is completely confused & disoriented. Her past history is remarkable for occasional transient ischemic attacks. EKG on the day of admission was essentially normal. Chest X-ray showed a small area of infiltrate in the left upper lung field near the hilum consistent with acute pneumonia, approximately 2 centimeters in diameter. Repeat chest X-ray 5 days after admission showed clearing of the infiltrate. Electrolytes returned to normal range 4 days after admission with potassium 4 & sodium 140. Blood cultures were negative. Urine culture showed greater than 100,000 of Streptococcus. Her fever came down 24 hours after admission, & she remained afebrile throughout the hospital course. Other vitals were within acceptable range. Appetite was very poor initially but but then progressed to 50% - 95% intake with all meals. Intravenous antibiotics were administered for pneumonia & urinary tract infection. The patient's intake & outputs were followed; approximately 4,000 cubic centimeters were noted during the first 3 days, & then this began to stabilize.The patient's mental status improved quite significantly over the course of the hospitalization, with increased alertness & responsiveness, although she remained confused & disoriented. She was able to sit in a chair without great difficulty & was eating quite well. She was discharged to the skilled nursing facility. FINAL DIAGNOSIS: Dehydration. Severe malnutrition. Acute left upper lobe pneumonia, improved. Alzheimer disease. Urinary tract infection due to Streptococcus.

Case Scenario 17, page 83: Patient admitted for chronic diarrhea. Small bowel series showed prominent jejunal diverticulitis near gastric anastomosis. Patient has history of gastric bypass surgery 10 years ago for obesity. Colonoscopy revealed a normal colon. Biopsies taken of the sigmoid colon were also normal. She was initially started on Tequin & Flagyl; however, her diarrhea did not improve. All stool studies were negative for Clostridium difficle. Her antibiotic regimen was changed to triple therapy, which included Cipro, Doxycycline, & Flagyl. She should be on this antibiotic regimen for one month. General surgery was consulted regarding evaluation of the patient as candidate for surgery to repair her jejunal diverticulum. She will first be tried on a prolonged course of triple antibiotic therapy & follow-up in general surgery as an outpatient for re-evaluation. Regarding her chronic diarrhea, as mentioned, by negative stool studies, she was ruled out for any infectious cause. Her thyroid blood tests were within normal range. In addition, patient underwent a colonoscopy specifically looking for microscopic colitis; however, the colon appeared normal and biopsies were normal. The patient is discharged home on triple antibiotic therapy & will follow up in the gastrointestinal clinic & with general surgery. PROCEDURE: Colonoscopy with biopsy of the sigmoid colon. FINAL DIAGNOSIS: Jejunal diverticulitis

Case Scenario 18, page 84: Patient admitted with history of left ureterolithiasis status post left ureteroscopy, laser lithotripsy, & stent placement 2 years prior. Her stent was removed approximately 1 month following the procedure, & she had no issues until a year later, when she presented to an outside physician complaining of left-side flank pain. CT scan was performed & revealed left hydronephrosis. She then underwent cystoscopy & retrograde pyelography, which revealed complete obstruction of the midureter. Left percutaneous nephrostomy tube was placed; & antegrade pyelogram was completed, which also revealed a complete obstruction. Renal scan was performed, which revealed a nonfunctioning left kidney with 12% function. She was then referred here for evaluation regarding left nephrectomy. Patient was admitted & underwent left nephrectomy without complication. She underwent preoperative bowel prep & was medicated with Kefzol 1 gm IV prophalactically. On post-operative day 1, the patient was tolerating clear liquids & was out of bed to chair. On post-operative day 2, her oxygen was weaned off & she was advanced to a regular diet, which she was tolerating well. On post-operative day 3, her Foley catheter was discontinued & she was urinating without difficulty. On post-operative day 4, she was afebrile with stable vital signs & good urine output. She had adequate oral intake & was ambulating without difficulty. Patient was discharged home on post-operative day 4, doing extremely well after procedure. PROCEDURE: Left nephrectomy (open approach) FINAL DIAGNOSIS: Nonfunctioning left kidney due to hydronephrosis

Case Scenario 19, page 84: Patient admitted for 34-week intrauterine pregnancy. This 34-year-old para 0-2-4-1 agrees with the 15-week sono, giving her a 34-week intrauterine pregnancy with estimated date of confinement for five weeks from now. She was recently hospitalized for elevated blood pressure & proteinuria. She received 2 doses of betamethasone. The patient left against medical advice. She is admitted today for increase in blood pressures to 180s over 100s & a headache. The unborn fetus had previously been transverse & today on ultrasound is vertex. Patient is crying & appears to be very upset about early delivery. She denies rupture of membranes or vaginal bleeding. Her prenatal labs include blood type B+, antibody negative, Pap within normal limits, positive PPD, rubella immune, hepatitis B surface antigen negative VDRL non-reactive, HIV negative. Cystic fibrosis screen negative. Toxo IgG & IgM negative. Patient has an obstetric history of spontaneous vaginal delivery with preterm labor times 2 at 35 & 36 weeks, proven to be 6 pounds, 5 ounces. Elective abortion times 2. Spontaneous abortion times two. She has a history of pre-eclampsia in both of her vaginal deliveries. The patient was admitted to labor & delivery unit, & she was thoroughly informed about having early delivery. It was discussed with her at length that the standard of care would be to induce her labor & have her deliver vaginally due to her pre-eclampsia. She was started on magnesium sulfate as seizure prophylaxis. Intravenous antibiotics were also started. It was decided that since she had severe pre-eclampsia, cesarean section was warranted. In addition, the patient also requested a bilateral tubal interruption. She stated that she understands the permanence of the procedure & the fact that there is a failure rate & an increased risk of ectopic pregnancy. A low cesarean was performed, which resulted in a single healthy male child weighing 6 pounds. Post-operatively, the patient was transferred to the mother/baby unit where she has remained without complaint. Her pain has been well controlled initially by IV medication & then by oral medication. Currently, she is ambulating & voiding without difficulty. She is tolerating a regular diet, & her lochia has been less than menses. On post-operative day 3, patient was discharged home. PROCEDURES: Low transverse cesarean delivery. Pomeroy bilateral tubal ligation. FINAL DIAGNOSIS: 34-week intrauterine pregnancy with severe pre-eclampsia

Case Scenario 23, page 86: The patient is an 81-year-old female who presented to the hospital with severe left upper quadrant pain & vomiting.There was a question of nephrolithiasis as she has had stones in the past. The patient was admitted to the hospital & started on intravenous therapy. The patient continued to have pain in the left upper quadrant & underwent an abdominal series, which was unremarkable. Chest X-ray was within normal limits except for the possibility of abnormality associated with 2 ribs on the left side. Chest & abdominal CT scans revealed fractures of the lower 2 ribs on the left side, no injury to the liver or spleen, & marked left hydronephrosis. The rib fractures were treated with pain management. The patient was seen in consultation for hydronephrosis; & the consultant thought that since this was a chronic condition & was unrelated to the patient's pain, no further workup was indicated. By day 7 of hospitalization, the patent was able to eat & was no longer vomiting & was thought to be stable for discharge. The patient left in improved condition. She will be seen in the office for follow-up in one month. FINAL DIAGNOSIS: Left upper quadrant abdominal pain due to pathological fracture of the lower two ribs on the left side. Hydronephrosis, left kidney

Case Scenario 24, page 86: This 48-year-old male is re-admitted because of current excruiating back pain due to herniated L4 disk. Complete blood count & urinalysis were normal. Glucose & electrolytes were normal. The patient was continued on his usual medication. He was started on Dolobid for pain & Flexeril as a muscle relaxant, used bed boards & was administered parenteral Demerol for pain. Physical therapy was started, from which the patient derived benefits. He had noted that his back was worse after he got up & went to the bathroom; the physical therapy exercises have helped with this. During hospitalization, reflexes were increased in the right lower extremity. The patient was discharged to family members at home, & he promised that he would stay at bed rest while he was home. The patient was discharged with bed rest, regular diet, & a follow-up appointment in one week. PROCEDURE: Physical therapy; therapeutic exercise; musculoskeletal system (lower back) FINAL DIAGNOSIS: Herniated L4 disk & lumbosacral strain

Case Scenario 25, page 87: A 5-year-old male diagnosed with polycystic disease of the kidneys, autosomal recessive type at age 3, is admitted at this time to undergo re-evaluation. Examination reveals normal blood pressure & average height for his age. Kidneys are slightly enlarged. The patient's mother stated that he had been complaining of painful urination, & she had noticed a bit of blood when he urinated. Urine culture was positive for E. coli, which was treated during in-patient hospitalization. Lab results revealed normal blood cell counts. CT scan of the kidneys revealed multiple cysts. Treatment options were discussed with the patient's parents, including the consideration of kidney transplant since there is no cure for polycystic kidney disease & the condition does not appear to recur in transplanted kidneys. FINAL DIAGNOSIS: Polycystic kidney disease, autosomal recessive type. Urinary tract infection due to Escherichia coli

Case Scenario 28, page 88: Patient is a 2-year-old white female who ingested approximately three-quarters of a Fleet enema at home & was brought to the emergency department. Ipecac was administered immediately, & the patient admitted for observation. During hospital course, the patient did not develop any shakiness & there were no side effects of low calcium & potassium. The child was doing well No diarrhea developed. No neurological deficit developed. On the 3rd hospital day, patient's vital signs were normal. No evidence of diarrhea noted. Father was instructed to call if any shakiness or diarrhea symptoms develop. Patient discharged home to the care of her father. FINAL DIAGNOSIS: Sodium (basic) phosphate poisoning due to ingestion of Fleet enema resolved without significant side effects. (Initial encounter)

Case Scenario 30, page 88: The patient is a 54-year-old white male who was a passenger in a car his son was driving. Apparently, the boy fell asleep at the wheel & the car was totaled. Patient was brought to the emergency room by ambulance. He is not sure whether he had any head trauma but complains primarily of pain in his left anterior chest & left shoulder. He was seen in the emergency room, which revealed that he had displaced fracture of his left fourth anterior rib. The physician did not see any fracture of the left shoulder but thought that there might be an acromioclavicular separation. The patient was admitted for observation & treatment of his pain. He had tenderness over the left third & fourth anterior ribs & very little use of his left shoulder. He also had tenderness to palpation over the acromioclavicular joint. The patient was admitted & started on analgesics. He did not have much movement of his left shoulder, although this gradually improved during his hospital stay. On the second hospital day, it was noted that he had very little movement of air in the left upper lobe; repeat chest X-ray was obtained, which showed a small pleural effusion on the left & possible pneumonia in the left lower lobe. He was started on Velosef, & the chest X-ray was repeated. The pleural effusion gradually resolved, & the area of pneumonia improved. The patient was continued on the Velosef. He was subsequently discharged. FINAL DIAGNOSIS: Automobile accident. Closed fracture, left fourth anterior rib. Possible acromioclavicular joint dislocation, left. Pneumonia. Pleural effusion. (Initial encounter)