SCENARIO Identifying Data: This 72-year-old female presents with a biopsy proven adenocarcinoma of the sigmoid colon at 20 cm.       History of Present Illness: The patient has been noted to have some bright red bleeding intermittently for approximately 8 months, initially presumable of a hemorrhoidal basis. She recently has had intensification of rectal bleeding but no weight loss, anorexia, or obstructive pain. No significant diarrhea or constipation. Some low back pain, probably unrelated. Recent colonoscopy by Dr. Scoma revealed a large sessile (attached by a broad base) polyp, which was partially excised at 20-cm level, showing infiltrating adenocarcinoma at the base. The patient is to enter the hospital at this time after home antibiotic and mechanical bowel prep, to undergo sigmoid colectomy and possible further resection.  1. Using the scenario above, answer the following questions: A. What chronic symptoms did this patient have? Describe the symptoms using medical terms. B. What was the cause of her chronic symptoms? C. What procedure did she have recently that diagnosed her condition? Name the procedure and briefly describe. D. The patient is scheduled for what procedure? Briefly explain the procedure.

3-2-1 Code It
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ISBN:9781337660549
Author:GREEN
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Chapter3: Icd-10-cm And Icd-10-pcs Coding Conventions
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SCENARIO

Identifying Data:

This 72-year-old female presents with a biopsy proven adenocarcinoma of the sigmoid colon at 20 cm.

 

 

 

History of Present Illness:

The patient has been noted to have some bright red bleeding intermittently for approximately 8 months, initially presumable of a hemorrhoidal basis. She recently has had intensification of rectal bleeding but no weight loss, anorexia, or obstructive pain. No significant diarrhea or constipation. Some low back pain, probably unrelated. Recent colonoscopy by Dr. Scoma revealed a large sessile (attached by a broad base) polyp, which was partially excised at 20-cm level, showing infiltrating adenocarcinoma at the base. The patient is to enter the hospital at this time after home antibiotic and mechanical bowel prep, to undergo sigmoid colectomy and possible further resection. 

1. Using the scenario above, answer the following questions:

A. What chronic symptoms did this patient have? Describe the symptoms using medical terms.

B. What was the cause of her chronic symptoms?

C. What procedure did she have recently that diagnosed her condition? Name the procedure and briefly describe.

D. The patient is scheduled for what procedure? Briefly explain the procedure.

 

 

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