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Instructions:After reading the clinical description, assign words or phrases from the paragraph to the term that best describes that concept. Note: Not all terms will have a match. IMPORTANT: As you review and identify items, please note you are not codingthe scenario; coding has many rules associatedwith how an encounter is coded. This exercise is purely about your ability to recognize the pathophysiology and pharmacology concepts that are found within the excerpts.Diagnos(es) - the identification of the nature of an illness or other problem by examination of the symptomsPrognosis -the likely course of a disease or ailmentEtiology -the cause, set of causes, or manner of causation of a disease or conditionSigns - an indication of a disease detectable by a medical practitioner even if not apparent to the patientSymptoms - a physical or mental feature that is regarded as indicating a condition of disease, particularly such a feature that is apparent to the patientComplications Sequelae -a condition that is the consequence of a previous disease or injuryNosocomial - (of a disease) originating in a hospital.TreatmentProcedureExamination of living tissueMedical History
Excerpt 1Kimberly is a 37-year-old white female who presented to her family doctor and was referred to radiation oncology department for consultation. While with the oncologist, Kimberly reported that both her mother and sister had breast cancer. She describes feeling heartburn for “a long time” and difficulty swallowing during the past 4 or 5 months. She feels like food occasionally seems to ‘catch’ in her throat, and describes pain immediately below the sternum that feels like a gnawing or burning. Other complaints include weight loss of 30 lbs. in the past 6 or 7 months, weakness and coughing at night. After performing an endoscopy and a biopsy of the esophageal tract, a cancerous tumor was identified and staged, and plans for radiation and an esophagectomy are underway.Diagnos(es)Cancerous tumorPrognosis N/AEtiology N/ASignsWeight lossSymptomsHeartburn, difficulty swallowing, pain below sternum after swallowing, weakness, coughing at nightComplicationsN/ASequelae N/ANosocomial N/ATreatmentRadiation, esophagectomyProcedureEndoscopy with biopsy of esophageal tractExamination of living tissuebiopsyMedical HistoryFamily history of breast cancer
Excerpt 2Jane is a 12 year old female who presents is being treated today for hypertension related to Congenital Adrenal Hyperplasia (CAH), which was discovered when a biopsy done of Jane’s mother’s placenta for genetic screening showed that both her parents were carriers for the gene. Fetal blood work completed confirmed an enzyme deficiency blocking gluticosteriod and mineralocorticoid hormones. Jane regularly receives hormonal treatment and future genitoplasty is being considered. Normal sexual functioning is anticipated with continued treatment.