HCS 214 Week 5 Urinary System–Analyzing a Progress Note

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 HCS 214 Week 5 Urinary System–Analyzing a Progress Note
 

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Urinary System – Analyzing a Progress Note

 

Part 1

 

Using the following progress note, define the highlighted terms within the chart provided. 

 

This patient is a resident in a Nursing Home and is being assessed by a local doctor.

 

Progress note:

 

Patient is a 68 y.o. male with history of kidney stones, urinary tract infection (UTI) and diabetes insipidus. Nursing staff reports a change in mental status, foul smelling urine, and increased incontinence with complaints of pain with urination.

 

On examination patient is alert. Patient notes having increased pain with urination and burning along with extreme pain in the lower abdomen at times. A urine culture was positive for e-coli bacteria. The urinalysis is positive for WBCs, RBC, and increased pH with results favorable for stone formation.

 

Plan to start Macrobid, increase fluid intake, repeat urinalysis and kidney function in the morning. Please catheterize the patient. Portable ultrasound in am. If positive will discuss possible cystoscopy and nephrology referral.

 

Impression: UTI, kidney stone

 

 

 

 

George, M.D.
 

 

 

 

*Do not forget to include the sources for your definitions.
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical term
 

 
 

 

Definition
 

 
 

 

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Part 2

 

Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical term
Medical code
Urinary Tract Infection (UTI)
N39.0 Urinary tract infection, site not specified 

 

P39.3 Urinary tract infection of newborn

 

N99.89 Other postprocedural complications and disorders of the genitourinary system

 

N36.9 Urethral disorder unspecified

 
Diabetes insipidus
N25.1 Nephrogenic diabetes insipidus 

 

E23.2 Diabetes insipidus

 

P70.2 Neonatal diabetes mellitus

 

E11.9 Diabetes mellitus without complications
Kidney stone
N28.1 Cyst of kidney, acquired 

 

S37.009A Injury to kidney without mention of open wound into cavity, unspecified injury, initial encounter

 

D30.00 Benign neoplasm of kidney, unspecified kidney

 

N20.0 Calculus of kidney
 

 

References
 

Centers for Medicare & Medicaid Services (23 Oct. 2014). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.” Retrieved from

https://www.cms.gov/medicare-coverage-database/staticpages/icd-10-code-lookup.aspx
 
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