The homework assignment requires coding for reports 2-5 located in the step-by-step workbook, specifically utilizing Encoder Pro. It details the medical history and treatment plans of several patients, including a 78-year-old female with pelvic metastatic cancer and complications, a 16-year-old with a sprained ankle, a 19-year-old post-kidney transplant patient with sepsis concerns, and ongoing management adjustments for diabetes. Students are instructed to complete a coding template that includes codes and their explanations for each report.

1. For this homework assignment, you will continue coding for
Reports 2-5, which are located on pages 182-184 of the Step-by-
Step Workbook. Using Encoder Pro, create codes for
information from Reports 2-5. Additionally, explain how you
arrived at that code.
Report 2: Discharge Summary
Diagnoses include:
1. Chronic pelvic pain secondary to pelvic metastatic clear cell
carcinoma of unknown primary location.
2. Vena Cava syndrome post placement of Hickman catheter.
3. Anemia due to chronic disease.
4. Hypertension.
HOSPITAL COURSE:
The patient is a 78 year old female whom we have been
following in our clinic for hypertension and also chronic
pudendal nerve pain. She had been recently diagnosed with
pelvic metastatic clear cell carcinoma, which her primary
location is unknown at this time. She will be discussing this
further after the pathology reports are read. During her hospital
stay a Hickman catheter was placed in order to have IV access
for pain medication or future cancer therapy. She was also
admitted for chronic pain. She did develop swelling of her arms
and neck. She was brought to interventional radiology and she
did have venography and the Hickman catheter was removed.
Her swelling to her arms and neck have decreased greatly. She
denies any shortness of breath. No choking sensation as

2. previously noted. Her pain has been managed well with fentanyl
patch at 175mcg. She has also been on IV heparin therapy for
anticoagulation following the vena cava syndrome. Today, the
patient has been having complaints of nausea. She did get some
dexamethasone IV for her nausea, which did improve later this
morning. Her blood pressure has been under good control. Her
labs today include a WBC of 5.18, hemoglobin 7.8, hematocrit
23.7, protime 14.4, INR 1.5, PTT 39.6, BUN 6, sodium 139,
potassium 4.2, and CO2 27.2.
DISCHARGE MEDICATIONS:
1. Will continue home medications.
2. Phenergan 12.5 1-2 tabs p.o. p.r.n. every 6 hours for nausea.
3. Lovenox 1 mg/kg subcutaneously every 24 hours.
4. Fentanyl patch 175 mcg to be changed every 3 days.
5. Epogen 40,000 units subcutaneously weekly at the Cancer
Center.
REPORT 3. CLINIC CHART NOTE
HISTORY: This 16 year old female is seen today after falling
off a curb and twisting her right ankle. She is normally a patient
of Dr. Anderson, who is out of town this week. She states that
she has pain surrounding the entire foot and ankle. Seems
unable or unwilling to bear weight.(Problem focused history)
PHYSICAL EXAM: Ankle and foot examined. Foot is warm to
the touch. Some swelling and bruising noted around the lateral
aspect of the ankle. X-ray is negative for fracture. (problem
focused examination)

3. IMPRESSION: Sprained right ankle. (MDM complexity
straightforward)
PLAN: Elevation; ice to affected area. Weight bearing only as
tolerated. Return for follow-up p.r.n.
REPORT 4: ADMIT INPATIENT
This is a 19 year old with a living-related donor kidney
transplant as of last month and admitted to hospital for possible
sepsis.
HISTORY: This patient has Type 1 diabetes and had been on
dialysis for a number of years before transplantation. She
received her mother's kidney on the 14th of last month from the
Medical Center Transplant Program in Dallas. She was there
this Tuesday for a transplant visit and apparently did not feel
well, but they were not certain whether this was a problem or
not; but they did go ahead and do blood cultures and called the
public health nurse, who was visiting the patient today, and said
that one of the cultures was positive for group B strep. The
home health nurse called me and stated that the patient has
really gone downhill the past few days and was quite fatigued
with generalized malaise. Denied cough, fever, or shaking chills
but looked poor overall, and the nurse was quite concerned. We
recommended she be brought here for evaluation and treatment
as an emergency. After arrival here, she was in no acute
distress. Initially, she had bibasilar crackles on deep breathing;
however, most of these cleared. I cannot hear any significant
pulmonary abnormality on auscultation or percussion. Her heart
is normal regular rhythm. No significant murmurs, rubs, S3, or
S4. Her abdomen is negative. Her left lower-quadrant kidney is
nontender. She has no lateralizing neural sounds. She is a little
lethargic. She does not feel warm. Apparently she is afebrile.

4. Her blood pressure is normal, and she is not tachycardic, but
she simply does not look well. Past history, social history, and
system review are per our recent old chart and noncontributory
at present.
CLINICAL IMPRESSION: One positive group B strep blood
culture, significance, and/or etiology to be determined. My
impression at this time is probably a significant finding, and I
suspect that this will become a progressive syndrome of not
treated.
ADDITIONAL DIAGNOSES:
1. Living-related donor kidney transplant
2. Diabetes mellitus type 1
3. Hypertension
REPORT 5: NEPHROLOGY HOSPITAL PROGRESS NOTE
This patient continues to be stable with no new problems. Her
cultures remain negative, and she remains afebrile. Her
clearance is pending, but she certainly has settled down nicely.
The main problem we are having is with her diabetic
management. It simply is not working with the former twice a
day of 70/30 insulin plus a nighttime Lantus. I think we should
go one way or the other, and we will go to Humalog before each
meal, starting with an estimated dose of 15 per meal and 40 of
Lantus in the evening, and we will titrate from there. We will
get Accu-Cheks before each meal to reflect the previous meal's
dose of Humalog and adjust it accordingly. Other than that,
tomorrow we will review her case with infectious disease with
regard to the duration of her antibiotic therapy. Thus far, our
cultures have remained negative; however, the positive group B

5. strep is not the type of typical contaminant you get in a blood
culture, and we must take it at face value.
You are to complete the homework template. Below is an
example:
It should be a chart with each report, a code and explanation of
code.
Please follow instructions!!!!!!!!!!!!!!!!!