Clinical Coding - Infective Exacerbation - COAD - Diabetic Ketoacidosis - Gastroparesis - Nursing Assessment Answer

Assessment Task:

Clinical Coding Nursing Assessment Answer

Coding Test
Please assign the appropriate ICD-10-AM and ACHI codes (11th Edition) to each of the following scenarios and episodes. 

Question

1.    This 64-year-old female was admitted with an infective exacerbation of her COAD. Her condition had been progressively declining over the previous week. On presentation, she was in acute respiratory failure and a chest X-ray revealed pneumonia. She is an ex-smoker, and this is believed to be the cause of her COAD. She was treated with IV antibiotics and recovered to her previous level of functioning. She was discharged home with an appointment for review regarding home oxygen therapy.

2.    This twenty-year-old male suffered a traumatic left retinal detachment whilst playing a game of Australian Rules football for his local club. The incident occurred following a heavy bump from a player in the opposing team. The patient is a current smoker and on regular medication for asthma. The procedure performed was a left scleral buckling under sedation (ASA 1). The patient was discharged home the following week.

3.    This twenty-eight-year-old man suffered self-inflicted full-thickness burns to his right forearm. He had doused himself in petrol and set himself alight. Fortunately, his brother was nearby and put the flames out immediately. Body surface area was 9%. In theatre under general anaesthetic (ASA 2E), he had the burns debrided and grafted with a split-thickness graft. He then had daily dressings to the area until his discharge five days later.

4.    This 18-year-old man was admitted with, diabetic ketoacidosis due to poor control of his Type I diabetes. He had diabetic complications of retinopathy and gastroparesis. He suffers chronic constipation due to his gastroparesis. His diabetes was brought under control, which corrected the ketoacidosis and he was started on ACTi lax for constipation. During the admission, he was also seen by a dietitian for assessment and provision of a therapeutic diet.

5.    This 70-year-old patient presented with ongoing pain and decreased range of movement following a fractured surgical neck of humerus sustained in a fall three months ago. On admission to the hospital, an x-ray revealed that the patient had a malunion of the fracture. They were taken to theatre where they underwent an open reduction with internal fixation and bone grafts to the fracture site under general anaesthetic (ASA 1).

6.    This thirty-six-year-old female smoker presented with squamous cell carcinoma of the left minor canthus. She underwent a full-thickness wedge excision of the lesion and a myocutaneous flap repair under general anaesthetic (ASA 1) before being discharged home two days after the procedure.

7.    This 39-year-old man was admitted following an attempted suicide. He had ingested 20 grams of Paracetamol and 20 Benzodiazepine tablets. He had no previous psychiatric history but did have considerable social pressures. Soon after admission, he developed hypokalaemia and was given replacement medication. He was also seen by the social worker whilst in hospital and was discharged with community-based follow-up care arranged.

8.    This 67-year-old man was admitted for same-day chemotherapy following a right hemicolectomy for adenocarcinoma of the large intestine several weeks ago. He had intravenous administration of 5FU chemotherapy, and bolus administration of folinic acid before being discharged home with his daughter.

9.    This patient was admitted for a termination of pregnancy at 17 weeks after a routine ultrasound revealed anencephaly. A D&E was performed under a general anaesthetic, prior to the patient being seen by the social worker and psychologist due to her pre-existing major depression.

10.    This 44-year-old patient was admitted to the day procedure centre for the investigation of abdominal pain. A colonoscopy was performed under sedation (ASA 2) and a polyp was identified and removed. No cause for abdominal pain was identified. The patient was discharged home once they had recovered from the sedation.

11.    This patient was admitted to the day procedure clinic for a gastroscopy and a colonoscopy (General Anaesthesia) to determine the cause of her longstanding anaemia. The gastroscopy noted the presence of mild oesophagitis, some chronic gastritis, and a hiatus hernia, while the findings of the colonoscopy included mild diverticular disease, a small rectal polyp that was excised, and some sigmoiditis. No definitive cause for the anaemia was identified and the patient was discharged home as soon as she was well enough.

12.    This 35-year-old woman was admitted for a total mastectomy and complete axillary clearance under general anaesthetic (ASA 1). Her surgery was uneventful. Histopathology confirmed poorly differentiated grade III ductal carcinoma of the upper inner quadrant, with clear margins. The lymphatic invasion was also noted, with the lymph nodes testing positive for metastatic carcinoma. She was discharged home and will have the first cycle of her chemotherapy in two weeks’ time.

13.    This patient was admitted after falling off a ladder at home. X-rays revealed a fractured humerus, a dislocated shoulder and an open wound to their upper left leg. The patients’ medical history includes chronic asthma, an appendicectomy (5 years ago), thyroid disease and Type II Diabetes. During their stay in hospital, the patients’ blood sugar levels were monitored daily leaving their diabetes stable. In theatre, the patient underwent an open reduction and internal fixation of their fractured humerus, a closed reduction of their dislocated shoulder and their open wound was sutured (General Anaesthetic). Post-surgery, the patient developed painful micturition. Urinalysis was performed and the results revealed evidence of pseudomonas, staphylococcal organisms and some E Coli. No further action was taken however as the specimen was deemed to be contaminated. The patients’ symptoms did resolve quickly, and they were soon discharged home.

14.    This 9-year-old girl was admitted with right-sided abdominal pain and associated vomiting and loss of appetite. She was observed overnight by which time the pain had improved and there was no further vomiting. She was discharged home with her mother and will be followed up by the family GP.

15.    This three-year-old boy was admitted for observation after presenting to the Emergency Department with a very high fever. He had been unwell for two days leading up to his admission with fever, generalised abdominal pain, vomiting, a sore throat and loose stools. The child was diagnosed with a viral illness and was discharged home. His parents were instructed to give him Panadol until the fever subsided and to visit their GP if there was still no improvement.

16.    This 19-year-old girl with a history of chronic tonsillitis and adenoiditis was admitted for tonsillo-adenoidectomy and turbinectomy under general anaesthetic (ASA 1, non-emergency). Her surgery was complicated by postoperative bleeding which required a return to theatre for control of haemorrhage under general anaesthetic (ASA 1E). She stayed in the hospital for a further two days and was then discharged home.

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