What Primary Diagnoses Explained for Students (Easy Guide)
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1. What is the Primary diagnoses codes , secondary diagnosis/diagnoses in alphabetic/numeric order codes , primary procedure codes , secondary procedure(s) is numeric order codes . Include ONLY the codes. Surgical Pathology Patient Case Number: SXP01-Williams, Carrie Patient Name: Carrie Williams DOB: 02-10-75 Sex: F Submitting Physician Brandon Smith, MD Attending Physician Nancy Smalls, MD Collected Date/Time 09-07-XX 11:20AM Received Date/Time 09-07-XX 11:30AM Accession Number: HL-11-34574 Clinical Summary/Clinical Impression: GI bleed, r/o sprue, H. pylori Gross Description:Part A-Received labeled small bowel in formalin are fragments of tissue collectively measuring about 1 cm in greatest dimension processed entirely. One block.Part B-Received labeled gastric in formalin are fragments of tissue collecting measuring about 0.8 cm in greatest dimension processed entirely. One block. Microscopic Description:Part A-Duodenal mucosa shows an intact villous architecture without increased intraepithelial lymphocytes. No Brunner gland hyperplasia, fovelolar metaplasia, active inflammation or Giardia are identified.Part B-Gastric mucosa shows mildly reactive appearing foveolar epithelium and underlying gastric glands with lamina propria showing fibromuscular tissue with scattered chronic inflammatory cells. No intestinal metaplasia is identified. Warthin-Starry stain reveals no Helicobacter pylori forms. Pathologic Diagnosis:Part A-Small bowel, duodenum biopsy No diagnostic abnormalityPart B-Stomach, biopsy Mild chronic gastritis Electronically Signed by: Peter Deutch, MD 2. What is the Primary diagnoses codes , secondary diagnosis/diagnoses in alphabetic/numeric order codes , primary procedure codes , secondary procedure(s) is numeric order codes . Include ONLY the codes. Surgical Pathology Patient Case Number: SXP04-Grier, Carol Patient Name: Carol Grier DOB: 12-22-63 Sex: F Submitting Physician Janet Dobson, MD Attending Physician Simon Powers, MD Collected Date/Time 04-01-XX 10:00AM Received Date/Time 04-01-XX 10:15AM Accession Number: JP-485-7741 Clinical Summary/Clinical Impression: R/O Candida Gross Description: The specimen consists of 25 ml. of hazy, colorless fluid with brush tip; two cytospin and one cell block preparation. Microscopic Description: The cytospin preparations consist of predominately many squamous cells and some fungal organisms morphologically consistent with Candida species. The cell block shows similar findings with less cellularity. Diagnosis: Esophageal brushings (cytospin and cell block preparations) No cells are diagnostic for malignancy. Some fungal organisms morphologically consistent with Candida species are present. Electronically Signed By: Sharon Walker, MD 3. What is the Primary diagnoses codes , secondary diagnosis/diagnoses in alphabetic/numeric order codes , primary procedure codes , secondary procedure(s) is numeric order codes . Include ONLY the codes. Surgical Pathology Patient Case Number: SXP07-Dubois, Stephanie Patient Name: Stephanie Dubois DOB: 07-07-52 Sex: F Submitting Physician Keith Sims, MD Attending Physician Noah Burkley, MD Collected Date/Time 11-19-XX 09:00AM Received Date/Time 11-19-XX 09:25AM Accession Number: LS-334-7658 Clinical Summary/Clinical Impression: Hx of breast ca, R/O mets Gross Description: Received in formalin labeled “left neck lymph node” consists of multiple tan-pink to light brown soft tissue that measures approximately 1.2 x 0.8 x 0.3 cm. The entire specimen is submitted in (A1). Final Diagnosis Specimen designated “left neck lymph node” biopsy Metastatic poorly differentiated carcinoma consistent with primary breast origin The specimen consists of multiple cores of lymph node that showed extensive infiltration by poorly differentiated malignant neoplasm. The malignant cells are arranged in the form of cords, nests, and groups of highly atypical cells with enlarged hyperchromatic nuclei. These findings support the morphologic evidence of poorly differentiated metastatic carcinoma with features consistent with invasive lobular carcinoma of the breast. Electronically Signed by: Jeremiah Singer, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved.
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