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 re-
view and identify items, please note you are
not coding
the scenario; coding has many rules associated
with how an encounter is coded.
This exercise is purely about your ability to recognize the pathophysiol-
ogy and pharmacology concepts that are found within the excerpts.
Contents
Excerpt 1
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2
Excerpt 2
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3
Excerpt 3
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4
Excerpt 4
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5
Excerpt 5
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Excerpt 6
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Excerpt 7
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Excerpt 8
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Excerpt 9
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Excerpt 10
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11
Excerpt 1
Kimberly 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 com-
plaints 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 malignant tumor/Esophageal tract cancer
Prognosis
NOS
Etiology
Genetics
Signs
Weight loss and coughing
Symptoms
Heartburn, difficulty swallowing, pain blow sternum and
weakness
Complications
NOS
Sequelae
NEC
Nosocomial
NEC
Treatment
Radiation
Procedure
Endoscopy, Esophagectomy
Examination of living tissue
Biopsy
Medical History
Mother/Sister with Breast Cancer
Excerpt 2
Jane 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.
Diagnos(es)
Hypertension related to CAH
Prognosis
Normal Sexual Functioning NSF
Etiology
Enzyme Deficiency
Signs
NOS
Symptoms
High Blood Pressure HBP
Complications
High Blood Pressure HBP
Sequelae
NOS
Nosocomial
NEC
Treatment
Regular Hormonal Treatment
Procedure
Genetic Screening
Examination of living tissue
Biopsy of placenta fetal blood work done to confirm con-
genital adrenal hyperplasia diagnosed as fetus
Medical History
Genetic screen reflected both parents carried the gene
Excerpt 3
James is a 43 y.o. male who complains of chest congestion and dry cough for 30 days. He has had a his-
