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CRC CHAPTER 13 EXPERIENTIAL LEARNING QUESTIONS WITH ANSWERS.
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CRC CHAPTER 13 EXPERIENTIAL LEARNING QUESTIONS WITH ANSWERS.
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CRC CHAPTER 13 EXPERIENTIALLEARNING QUESTIONS WITH
ANSWERS.
Question 1
Date: 03/01/20XX Date of Birth 09/01/XX
Vital Signs: BP 137/77, Left Arm. Pulse: 83. Temperature: 97.0 F. HT: 5'3". WT: 233 lbs.
BMI: 41.31 kg/m2.
Subjective
This patient is a XX years-old female who presents for evaluation of breast pain.(Breast pain is main
reason for the visit.)
Duration: Three weeks. Location: right. Onset: gradual. Quality: achy, sore. Redness: no. Swelling: no.
Treatments attempted: none. Breast lump: no. Previous mammogram: yes, done elsewhere last year.
Past Medical History
Breast biopsy: No
Major Problem: LONG-TERM USE MEDS NEC
Major Problem: ATRIAL FIBRILLATION (A FIB)
Major Problem: DM 2 W/O CMP (DM treated with Glipizide.)
Major Problem: HYPERLIPIDEMIA (Hyperlipidemia treated with Lovastatin.)
Major Problem: FIBROMYALGIA
Major Problem: OSTEOARTHRO (OA treated with Aleve and Calcium.)
Major Problem: CONGESTIVE HEART FAILURE (CHF) (CHF treated with Furosemide.)
Surgical / Proced ANS - N64.4, I48.91, E66.01, E11.9, E78.5, Z95.2, Z68.41, I11.0, I50.9,M79.7, M19.90,
Z87.891, Z79.01, Z79.84, Z79.1
Response Feedback:
Rationale: In this example the patient is diagnosed with mastalgia. In the Alphabetic Index look for
Mastalgia, which directs you to N64.4. The patient also has atrial fibrillation, type 2 diabetes, morbid
, obesity with a BMI of 41.31, hyperlipidemia, CHF, and had a valve replacement. In the Alphabetic Index
look for Fibrillation/atrial which directs you to I48.91; Diabetes, diabetic (mellitus) (sugar)/type 2 which
directs you to E11.9; Obesity/morbid which directs you to E66.01; Body/mass index (BMI)/adult/40.0-
44.9 which directs you to Z68.41; Hyperlipidemia which directs you to E78.5; Hypertension/heart/with
heart failure directs you to I11.0; Failure/heart/congestive which directs you to I50.9;
Presence/artificial/heart/valve which directs you to Z95.2. The patient also has fibromyalgia,
osteoarthritis, long-term use of anticoagulants, and history of smoking. In the Alphabetic Index look for
Fibromyalgia which directs you to M79.7; Osteoarthritis which directs you to M19.90 and
Long-term/anticoagulants which directs you to Z79.01; History/tobacco dependence refers the coder to
Z87.891. The patient's diabetes is controlled with oral medication. Look in the ICD-10-CM Alphabetic
Index for Long-term (current) drug therapy (use of)/oral/hypoglycemics, which directs you to Z79.84.
The patient is also taking NSAIDS, in the Alphabetic Index look for Long-term drug therapy use/Non-
steroidal anti-inflammatories (NSAID) which directs you to Z79.1. Verify all code selections in the Tabular
List. Although diabetes, hyperlipidemia, fibromyalgia, and OA are not included in the assessment, the
conditions are documented in the history and being treated with prescriptions which makes the
conditions conside
Question 2
NEW PATIENT CONSULTATION
HISTORY OF PRESENT ILLNESS: I had the pleasure of meeting Ms. F today. A pleasant 71 year-old white
female who comes to our office with recently abnormal CT of the abdomen and pelvis.(Main reason for
this visit is abnormal CT of the abdomen and pelvis.) Back in September she was seen at an emergency
room with complaint of syncope, was hospitalized at that time, now resolved. During her stay she
complained of diarrhea with nausea as well as right lower quadrant abdominal pain. On a CT of the
abdomen and pelvis (Previous CT of ABD and pelvis shows peri colonic stranding but not sure where and
diverticulosis.) there was notice of pericolonic stranding at the cecum versus ileocecal valve as well as
some left colonic diverticulosis, uncomplicated. Appendicitis (Appendicitis would not be coded because
its being ruled out.) could not be ruled out, however, the patient has had complete re ANS - R93.5, I10,
R32, M19.90,R51.9, H93.19, Z88.6, Z79.1
Response Feedback:
Rationale: In this case the patient has an abnormal CT. In the Alphabetic Index, look for
Abnormal/diagnostic imaging/abdominal, abdominal region which directs you to R93.3. The patient has
hypertension, urinary incontinence, osteoarthritis, and headaches. In the Alphabetic Index, look for
Hypertension, which directs you to I10; Incontinence/urinary, which directs you to R32; osteoarthritis,
which directs you to M19.90; and headaches, which are not further specified by the provider, directs
you to R51.9, Headache, unspecified. The patient also complains of ear pain and ringing. In the
Alphabetic Index, look for Tinnitus, which directs you to H93.1-. In this case we do not know which ear is
affected so the unspecified codes would be assigned. The patient has an allergy to Aleve, in the
Alphabetic Index look for History of/personal/allergy to/analgesic agent, which directs you to Z88.6. The
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