CCS ICD practice questions Part 4

1. Inpatient admission: The patient, an elderly man, was admitted through the emergency
department for severe urinary retention. In the emergency department, it was also
determined that his hypertension was accelerated. He had been hospitalized three months
earlier for identical problems, and he said he had not taken any of his medications since the
last hospitalization, as he could not afford the cost. The urinary retention was relieved by
placement of a Foley catheter. Medications were started, and the hypertension improved
rapidly. The patient was evaluated for the extent of benign prostatic hypertrophy.
Transurethral resection of the prostate was recommended, but it was refused by the
patient.

Discharge diagnoses: (1) Hypertensive urgency, (2) acute urinary retention secondary to
benign hypertrophy of the prostate, (3) noncompliance with treatment program

2. Inpatient admission: The patient was admitted for recurrent epistaxis that did not respond
to nasal packing in the emergency department. He was status post myocardial infarct seven
weeks earlier, with no current symptoms. An EKG was performed to evaluate the status of
the MI. The patient also suffered from a deviated nasal septum. Multiple attempts were
made to stop the bleeding with more packing, but none was successful for more than a few
hours. Therefore, the following procedures were performed: (1) anterior and posterior nasal
packing, (2) endoscopic ethmoidal artery ligation, (3) endoscopic septoplasty. He was
transfused via peripheral vein with two units of packed red cells during the operation.

Discharge diagnoses: (1) Severe and recurrent epistaxis, (2) post myocardial infarct, (3)
deviated nasal septum.

3. Inpatient admission: The reason for the patient’s admission was substernal chest pain with
some arm involvement. A combined right and left selective low osmolar contrast coronary
angiography with fluoroscopy and a bilateral low osmolar contrast pulmonary angiography
were performed. No coronary artery disease or pulmonary embolus was found.

Discharge diagnosis: Chest pain without occlusive coronary artery disease.

4. Inpatient admission: The patient, a 19-year-old man, was transferred from another hospital
with intractable headache. The accompanying CT scan was normal, but clinical
symptomatology was suggestive of subarachnoid hemorrhage. Lumbar puncture, non-
contrast bilateral internal carotid cerebral arteriogram, and contrast cerebral MRI were all
normal. When the findings were discussed with the patient, he became increasingly
belligerent. Although his headaches were only somewhat improved, he refused further
treatment and was discharged for follow-up with his own physician.

Discharge diagnosis: Headache.

5. Inpatient admission: The patient has a known diagnosis of prostatic cancer. He started
having fevers approximately one week earlier. The fevers did not respond to outpatient
antibiotics. Blood and urine cultures showed no growth. He was admitted for workup of the
fevers with possible prostatic abscess formation. There were no obvious signs of infection or
abscess on a transrectal ultrasound of the prostate. An iodine-123 radioisotope bone scan of
the body revealed no skeletal metastases. The antibiotic therapy was changed, and he was
given an IV push. He improved and was discharged.

Discharge diagnoses: (1) Fever of unknown origin, (2) cancer of the prostate.

6. Inpatient admission: The two-year-old patient had an acute onset of fever and some shaking
chills at home. He was thought to have experienced a febrile seizure and was admitted for
workup and treatment. There was some infiltrate in the right lung per chest X-ray. All
laboratory work was within normal limits. He was observed during his stay. No problems
were noticed, and he remained afebrile after the first day. He was discharged for office
follow-up.

Discharge diagnosis: Rule out febrile seizure.

7. Inpatient admission: The patient was admitted through the emergency department with
possible acute cholecystitis. She had severe abdominal pain and a markedly elevated white
count. A gallbladder ultrasound, cholecystogram, and contrast intravenous pyelogram were
all normal. The next day her pain was almost gone, and the white blood count dropped to
nearly normal. It was not felt worthwhile to continue the workup.

Discharge diagnoses: (1) Abdominal pain, (2) leukocytosis.

8. Inpatient admission: The patient, an obese male, was admitted with generalized abdominal
pain suggestive of early appendicitis, although he had a normal white count and normal
differential. An intravenous pyelogram and X-ray of the lower gastrointestinal tract with
barium enema were negative. All laboratory studies were normal. He improved while in the
hospital without a definite cause for his pain ever being identified. He was placed on a low-
fat, 1,500-calorie diet prior to discharge.

Discharge diagnoses: (1) Abdominal pain of undetermined origin, generalized; (2) obesity.

9. Outpatient clinic visit: This patient with type 2 diabetes was seen by his primary care
physician for evaluation of an inconclusive liver function scan and abdominal pain. The
physician ordered a CT scan of the liver and advised the patient to return in one week.

Discharge diagnosis: Abnormal liver function, upper right quadrant abdominal pain, and
diabetes mellitus.

10. Inpatient admission: The patient, a woman with type 1 diabetes, was admitted because of
increased swelling of the right foot that was determined to be an abscess. Staphylococcus
aureus grew from the abscess. She underwent a percutaneous incision and drainage of the
foot abscess. Her course in the hospital otherwise was essentially unremarkable. The foot
gradually improved with antibiotic therapy, hyperbaric oxygen therapy, and daily whirlpool
therapy.

Discharge diagnoses: (1) Abscess right foot, (2) type 1 diabetes mellitus.

11. Inpatient admission: The child was admitted with a fever and lethargy. The admitting
diagnosis was “rule out sepsis.” When admitted, he was responsive but lethargic. The
physical examination was within normal limits except for the left eardrum, which was
reddened. He was placed on intravenous antibiotics after the full septic workup was
complete. Improvement was evident by the next day, when he was alert, active, and started
on feedings. He became afebrile and was discharged on oral antibiotics for otitis media, with
sepsis ruled out.

Discharge Diagnosis: (1) Fever, (2) otitis media.

12. Inpatient admission: The patient, a 10-month-old male, presented with acute stridor and
respiratory distress. His mother felt that he had possibly choked on a peach. Nothing was
seen on chest X-ray. A rigid bronchoscopy ruled out foreign body, but the findings were
consistent with croup. He was discharged on medication to follow up with his pediatrician in
one week.

Discharge diagnosis: Croup.

13. Emergency department visit: A 26-year-old male, involved in a car crash, was taken to the
local emergency department (ED) in a coma, where he was diagnosed with a traumatic brain
injury with loss of consciousness of one hour. Glasgow coma scale (GCS) was 6 on arrival in
the ED. Patient was transferred to a trauma center for further care.

Discharge diagnosis: Traumatic brain injury.

14. Inpatient admission: This HIV-positive patient was admitted with skin lesions on the chest
and back. Excisional biopsies were taken, and the pathological diagnosis was Kaposi’s
sarcoma. Leukoplakia of the lips and splenomegaly were also noted on physical
examination.

Discharge diagnoses: (1) HIV infection; (2) Kaposi’s sarcoma, back and chest; (3) leukoplakia;
(4) splenomegaly.

15. Inpatient admission: The patient underwent an outpatient laparoscopic-assisted

cholecystectomy for cholecystitis and was admitted the next day because of a flare-up of
chronic hepatitis C. The chronic hepatitis C was secondary to intravenous drug use. With
medication, the chronic hepatitis C was controlled, and the woman was discharged.

Discharge diagnoses: (1) Chronic hepatitis C, (2) IV drug dependence.

16. Inpatient admission: An elderly male patient with a history of benign hypertension became
extremely febrile the day before admission. On admission, he was extremely lethargic with a
possible septic urinary tract infection. He was pan cultured and started on IV antibiotics and
fluids. Pseudomonas showed in the urine culture. The next day, his mind was quite clear and
the fever defervesced from an initial 104.6 to 99.0 degrees. However, he had gross
hematuria. As the IV fluids were decreased, he resumed his usual hypertensive state. By the
third hospital day, the urine had cleared and he was discharged on oral antibiotics, with
septicemia ruled out.
17. Inpatient admission: The patient, with arteriosclerotic coronary heart disease and type 2
diabetes mellitus, came to the hospital with symptoms that were believed to represent
sepsis. She was placed on antibiotics, and the symptoms improved. ST- and T-wave changes
were evident on an EKG. The patient’s glucose showed marked elevation, thought to be
secondary to the sepsis. The blood sugars were brought under control with an adjustment of
her insulin therapy and an appropriate diet.

Discharge diagnoses: (1) Arteriosclerotic coronary heart disease, (2) uncontrolled type 2
diabetes mellitus, (3) questionable sepsis.

18. Outpatient clinic visit: The HIV-infected patient was suffering from an acute lymphadenitis
due to his HIV infection. The glands in the neck area were most affected. Antibiotics were
prescribed, but the patient refused antiretroviral treatment at this time. He was of the
opinion that his religion would eventually make antiretroviral medication unnecessary.
Another consideration was his narcotic dependency. He was encouraged to continue
participation in support groups for people with narcotic addiction and HIV.

Diagnoses: (1) Acute lymphadenitis secondary to HIV infection, (2) narcotic dependence, (3)
refusal of medication due to religious reasons.

19. Inpatient admission: The patient is an 85-year-old female who presented to the emergency
department (ED) with increasing shortness of breath, hypoxia, productive cough, and
progressive weakness. She acutely deteriorated in the ED and was emergently sent to the
intensive care unit (ICU). In the ICU, the patient was intubated, mechanically ventilated for
four days, and started on broad-spectrum antibiotics.

Diagnoses: (1) Septic shock, (2) acute respiratory failure, (3) Hemophilus influenzae
pneumonia.