HCS 214 Wk 5 - Urinary System—Analyzing a Progress Note

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HCS/214 v6

Urinary System – Analyzing a Progress Note

HCS/214 v6

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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 who is status post laparoscopic radical prostatectomy for prostate cancer. He has a history of incontinence and kidney stones. He returns today for a follow-up and PSA check. PSA from two days ago was less than 0.1. Nursing staff reports in terms of continence, he is doing well. He utilizes one partial pad per day. He has done his Kegel exercise regularly and we have encouraged him to continue with Kegels and do expect a full recovery.

On examination the patient is alert. In terms of potency, he did have a bilateral nerve-sparing procedure and is eligible for recovery of erections. He is interested in this, and we have therefore outlined the therapeutic benefits of medications as well as vacuum pump therapy.

Plan to start Cialis 20 mg every three days and will use the vacuum pump multiple times a week. He does not have contraindications to do these therapeutic treatments. Schedule a follow-up ultrasound and nephrology referral.

Impression: Status post laparoscopic radical prostatectomy with undetectable PSA. Stress incontinence. Erectile dysfunction.

D. George, M.D.

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

40 Points: 1 point for Medical term, 2 points for Definition, and 1 point for Sources

Medical term	Definition	Sources
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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.

30 points: 10 for each correct answer.

Medical term	Medical code
Erectile Dysfunction	N99.89 Other post procedural complications and disorders of the genitourinary system N36.9 Urethral disorder unspecified N52.32 Erectile dysfunction following radical cystectomy N52.9 Male erectile dysfunction, unspecified
Stress Incontinence	N39.498 Other specified urinary incontinence N39.3 Stress incontinence (female) (Male) R32 Unspecified urinary incontinence R39.81 Functional urinary incontinence
Prostate Cancer	N42.83 Cyst of prostate N41.8 Other inflammatory diseases of prostate C61 Malignant neoplasm of prostate D29.1 Benign neoplasm of prostate

References

Centers for Medicare & Medicaid Services (23 Oct. 2015). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.”

HCS 214 Wk 5 - Urinary System—Analyzing a Progress Note

Urinary System – Analyzing a Progress Note

Part 1

Medical term

Definition

Sources

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

Part 2

References