MRC135 Portfolio Project.
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MRC135 Portfolio Project
Frank Skwierc
Bryant & Stratton College Online Campus
MRC 135 Diagnostic Coding
Instructor Catina L Flagg
October, 24, 2015
MRC135 Portfolio Project.
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Case Study 1
Emergency Department:
DIAGNOSES: Concussion with 5 minutes loss of consciousness. Shortness of breath. Painful
respiration. Rales. Fall from horse (non-collision) while horseback riding in the paddock at a
horse farm (initial encounter).
PROCEDURES: Level 2 ED service. Complete skull x-ray. Chest x-ray (2-view). CBC.
Urinalysis.
Laboratory Department: CBC, Urinalysis
Jessica Bowman is a 28-year-old female who presents to the emergency department (ED) after a
fall from her horse. She states that she is not sure what happened. She just "came to" after about
five minutes in the field where she had been exercising her prize barrel-racer in the paddock at
the Cooper Horse Farm. She complains of shortness of breath and pain upon inhalation. Ms.
Bowman appears to be a well-nourished young woman in good physical condition. She denies
smoking and states she uses alcohol on occasion. She is multipara x 2, multigravida x 3, and
states that she may be a "little" past the due date of her menstrual cycle. She is afebrile.
Neurological signs are within the normal range, eyes PERRLA, and her musculoskeletal range of
motion is normal. She has heart sounds with regular rate and rhythm, abdomen soft, normoactive
bowel sounds, and her lungs have crackles (rales) upon auscultation. The physician ordered a
frontal and lateral chest x-ray with oblique projections, skull x-ray, automated CBC, nonautomated urinalysis. All radiologic and laboratory results were negative.
MRC135 Portfolio Project.
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CASE STUDY WORKSHEET
PATIENT DOCUMENTATION
CASE STUDY #:
1
PRINCIAL DIAGNOSIS:
MEDICAL REPORT #:
Concussion less than 30 minutes 850.11
SECONDARY OR OTHER DIAGNOSIS:
Shortness breath 786.05., Painful respiration 786.52, Rales 786.7
Level 2 ED Complete Skull x-ray 87.17
PRINCIPAL PROCEDURE:
OTHER PROCEDURE:
Jessica Bowman 28 year old female, E006.1, E849.1
Chest x-ray (two views)V72.5, CBC urinalysis V72.60,
ADDITIONAL DOCUMENTATION
NEEDED:
Report show 3x pregnant but only went to term twice since is past due for menstrual
Cycle this may have a bearing on the diagnosis.
QUESTIONS FOR PHYSICIAN:
Clarify with the physician whether the concussion is still in the acute stage or if it is a postconcussion syndrome.