Sadie Thompson, an 18-month-old female, was born with TAR syndrome
(thrombocytopenia with absent radius). Sadie is brought in today by her
mother with the complaint of excessive bruising without significant trauma.
After an examination and the laboratory tests are completed, Dr. Dotson
diagnosis Sadie with congenital thrombocytopenia purpura.
Q87.2: Thrombocytopenia>with absent of radius (TAR)
D69.42: Purpura>thrombocytopenia>congenital
Juanita Ilderton, a 41-year-old female, received a blood transfusion 12 hours
ago; now she is experiencing fever, chills, and dizziness. A direct Coombs’ test
is performed, which confirms a diagnosis of acute Rh blood transfusion
incompatibility after a transfusion.
T80.410A: Complication>transfusion>Rh>acute
Rosalyn Burkett, a 37-year-old female, presents today with the complaint of
migraines and blurred vision. After an examination and a review of the
laboratory tests, Dr. Flick diagnoses Rosalyn with Lupus anticoagulant
syndrome.
D68.62: Syndrome>lupus anticoagulant
Tilley Cabe, a 9-month-old female, is brought in to see Dr. Peterson, her
pediatrician. Tilley has had a persistent low-grade fever for 4 days that has not
diminished. Dr. Peterson notes a temperature of 100.2 and splenomegaly.
Tilley is not thriving. Dr. Peterson admits her to the hospital. The laboratory
results reveal Tilley has a low natural killer cell activity and cytopenia, which
confirm the diagnosis of hemophagocytic lymphohistiocytosis (HLH).
D76.1: Lymphohistiocytosis>hemophagocytic
Richard Greene, 33-year-old male, comes to see Dr. Walter with the
complaints of tiredness and weakness. Dr. Walter completes bloodwork and a
bone marrow biopsy. Richard is diagnosed with chronic lymphocytic, B-cell
type leukemia.
C91.10: Leukemia> chronic lymphocytic, of B-cell type>NOS
Sam Goodman, a 9-year-old male, presents today for a sports physical in
order to play on his school baseball team. Dr. Inabinet notes splenomegaly.
The results from the CBC test and peripheral blood smear confirm a diagnosis
of Hb-C disease.
D58.2: Disease>hemoglobin>C
,Ivory Presnell, a 75-year-old female, comes in today complaining of fever,
chills, and night sweats. She says she feels tired and has lost 5 lbs. within a
week. Dr. Shirley notes nail clubbing and completes an in-house CBC test;
results: hemoglobin of 7.9 g/dL. Ivory is admitted to Weston Hospital, where a
tissue biopsy is taken, returning a positive reading for extra-pulmonary
tuberculosis. Ivory is diagnosed with anemia due to tuberculosis.
A18.89: Anemia>tuberculous
D63.8: Anemia>due to chronic diseases classified elsewhere
Billy Stevenson, a 10-year-old male, is brought in by his father to see Dr.
Loveichelle. Billy has developed a cough and fever. Billy says he feels really
tired. Mr. Stevenson also stated they can’t get Billy to eat. Dr. Loveichelle
completes an examination and an in-house CBC. Billy’s hemoglobin is 7.4
g/dL. Billy is admitted to the hospital for a full workup. Once all the laboratory
results have been reviewed, Billy is diagnosed with hookworm anemia.
B76.9: Anemia>hookworm
D63.8: Anemia>due to>chronic disease classified elsewhere NEC
Victor Motts, a 6-month-old male, is brought in by his mother to see his
pediatrician, Dr. Stewart. Victor experienced a type of spasm. Dr. James notes
skeletal abnormalities and cyanosis as well as some hearing difficulties and
admits him to Weston Hospital. A fluorescence in situ hybridization (FISH)
blood test confirms a diagnosis of Di George’s syndrome.
D82.1: Syndrome>Di George’s
, ANYTOWN ANESTHESIOLOGY ASSOCIATES
241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234
PATIENT: DRESSLER, SIMONE
ACCOUNT/EHR #: DRESSI001
DATE: 11/15/18
Preoperative DX: Chronic cholelithiasis
Postoperative DX: Chronic cholelithiasis; subacute cholecystitis
Procedure: Laparoscopic cholecystectomy; intraoperative cholangiogram
Attending Physician: Renee O. Bracker, MD
Anesthesia: General endotracheal
Anesthesiologist: Melinda Abruzzo, MD
PROCEDURE: The patient, a 57-year-old female, was taken to the OR. The
patient was induced and an endotracheal tube was placed. The patient was
then placed in the supine position. The abdomen was prepped and draped in
the usual fashion. The patient had several previous lower midline incisions
and right flank incision; therefore, the pneumoperitoneum was created via
epigastric incision to the left of the midline with a Verres needle. After
adequate pneumoperitoneum, the 11-mm trocar was placed through the
extended incision in the left epigastrium just to the left of the midline, and the
laparoscope and camera were in place. Inspection of the peritoneal cavity
revealed it to be free of adhesions, and another 11-mm trocar was then
placed under direct vision through a small infraumbilical incision. The scope
and camera were then moved to this position, and the gallbladder was easily
visualized. The gallbladder was elevated, and Hartmann’s pouch was
grasped. Using a combination of sharp and blunt dissection, the cystic artery
was identified. The gallbladder was somewhat tense and subacutely inflamed.
Therefore, a needle was passed through the abdominal wall into the
gallbladder, and the gallbladder was aspirated free until it collapsed. One of
the graspers was held over this region to prevent any further leakage of bile.
Again, direction was turned to the area of the triangle of Calot. The cystic duct
was dissected free with sharp and blunt dissection. A small opening was made
in the duct, and the cholangiogram catheter was passed. The cholangiogram
revealed no stones or filling defects in the bile duct system. The biliary tree
(thrombocytopenia with absent radius). Sadie is brought in today by her
mother with the complaint of excessive bruising without significant trauma.
After an examination and the laboratory tests are completed, Dr. Dotson
diagnosis Sadie with congenital thrombocytopenia purpura.
Q87.2: Thrombocytopenia>with absent of radius (TAR)
D69.42: Purpura>thrombocytopenia>congenital
Juanita Ilderton, a 41-year-old female, received a blood transfusion 12 hours
ago; now she is experiencing fever, chills, and dizziness. A direct Coombs’ test
is performed, which confirms a diagnosis of acute Rh blood transfusion
incompatibility after a transfusion.
T80.410A: Complication>transfusion>Rh>acute
Rosalyn Burkett, a 37-year-old female, presents today with the complaint of
migraines and blurred vision. After an examination and a review of the
laboratory tests, Dr. Flick diagnoses Rosalyn with Lupus anticoagulant
syndrome.
D68.62: Syndrome>lupus anticoagulant
Tilley Cabe, a 9-month-old female, is brought in to see Dr. Peterson, her
pediatrician. Tilley has had a persistent low-grade fever for 4 days that has not
diminished. Dr. Peterson notes a temperature of 100.2 and splenomegaly.
Tilley is not thriving. Dr. Peterson admits her to the hospital. The laboratory
results reveal Tilley has a low natural killer cell activity and cytopenia, which
confirm the diagnosis of hemophagocytic lymphohistiocytosis (HLH).
D76.1: Lymphohistiocytosis>hemophagocytic
Richard Greene, 33-year-old male, comes to see Dr. Walter with the
complaints of tiredness and weakness. Dr. Walter completes bloodwork and a
bone marrow biopsy. Richard is diagnosed with chronic lymphocytic, B-cell
type leukemia.
C91.10: Leukemia> chronic lymphocytic, of B-cell type>NOS
Sam Goodman, a 9-year-old male, presents today for a sports physical in
order to play on his school baseball team. Dr. Inabinet notes splenomegaly.
The results from the CBC test and peripheral blood smear confirm a diagnosis
of Hb-C disease.
D58.2: Disease>hemoglobin>C
,Ivory Presnell, a 75-year-old female, comes in today complaining of fever,
chills, and night sweats. She says she feels tired and has lost 5 lbs. within a
week. Dr. Shirley notes nail clubbing and completes an in-house CBC test;
results: hemoglobin of 7.9 g/dL. Ivory is admitted to Weston Hospital, where a
tissue biopsy is taken, returning a positive reading for extra-pulmonary
tuberculosis. Ivory is diagnosed with anemia due to tuberculosis.
A18.89: Anemia>tuberculous
D63.8: Anemia>due to chronic diseases classified elsewhere
Billy Stevenson, a 10-year-old male, is brought in by his father to see Dr.
Loveichelle. Billy has developed a cough and fever. Billy says he feels really
tired. Mr. Stevenson also stated they can’t get Billy to eat. Dr. Loveichelle
completes an examination and an in-house CBC. Billy’s hemoglobin is 7.4
g/dL. Billy is admitted to the hospital for a full workup. Once all the laboratory
results have been reviewed, Billy is diagnosed with hookworm anemia.
B76.9: Anemia>hookworm
D63.8: Anemia>due to>chronic disease classified elsewhere NEC
Victor Motts, a 6-month-old male, is brought in by his mother to see his
pediatrician, Dr. Stewart. Victor experienced a type of spasm. Dr. James notes
skeletal abnormalities and cyanosis as well as some hearing difficulties and
admits him to Weston Hospital. A fluorescence in situ hybridization (FISH)
blood test confirms a diagnosis of Di George’s syndrome.
D82.1: Syndrome>Di George’s
, ANYTOWN ANESTHESIOLOGY ASSOCIATES
241 MAIN STREET • ANYTOWN, FL 32711 • 407-555-1234
PATIENT: DRESSLER, SIMONE
ACCOUNT/EHR #: DRESSI001
DATE: 11/15/18
Preoperative DX: Chronic cholelithiasis
Postoperative DX: Chronic cholelithiasis; subacute cholecystitis
Procedure: Laparoscopic cholecystectomy; intraoperative cholangiogram
Attending Physician: Renee O. Bracker, MD
Anesthesia: General endotracheal
Anesthesiologist: Melinda Abruzzo, MD
PROCEDURE: The patient, a 57-year-old female, was taken to the OR. The
patient was induced and an endotracheal tube was placed. The patient was
then placed in the supine position. The abdomen was prepped and draped in
the usual fashion. The patient had several previous lower midline incisions
and right flank incision; therefore, the pneumoperitoneum was created via
epigastric incision to the left of the midline with a Verres needle. After
adequate pneumoperitoneum, the 11-mm trocar was placed through the
extended incision in the left epigastrium just to the left of the midline, and the
laparoscope and camera were in place. Inspection of the peritoneal cavity
revealed it to be free of adhesions, and another 11-mm trocar was then
placed under direct vision through a small infraumbilical incision. The scope
and camera were then moved to this position, and the gallbladder was easily
visualized. The gallbladder was elevated, and Hartmann’s pouch was
grasped. Using a combination of sharp and blunt dissection, the cystic artery
was identified. The gallbladder was somewhat tense and subacutely inflamed.
Therefore, a needle was passed through the abdominal wall into the
gallbladder, and the gallbladder was aspirated free until it collapsed. One of
the graspers was held over this region to prevent any further leakage of bile.
Again, direction was turned to the area of the triangle of Calot. The cystic duct
was dissected free with sharp and blunt dissection. A small opening was made
in the duct, and the cholangiogram catheter was passed. The cholangiogram
revealed no stones or filling defects in the bile duct system. The biliary tree
