1. What is the Primary diagnoses codes , secondary… 1. Wh
1. What is the Primary diagnoses codes , secondary… 1. What is the Primary diagnoses codes , secondary diagnosis/diagnoses in alphabetic/numeric order codes , primary procedure codes , secondary procedure(s) is numeric order codes . Include ONLY the codes. Surgical PathologyPatient Case Number: SXP01-Williams, CarriePatient Name: Carrie WilliamsDOB: 02-10-75Sex: FSubmitting PhysicianBrandon Smith, MDAttending PhysicianNancy Smalls, MDCollected Date/Time09-07-XX 11:20AMReceived Date/Time09-07-XX 11:30AMAccession Number: HL-11-34574Clinical Summary/Clinical Impression: GI bleed, r/o sprue, H. pylori Gross Description:Part A-Received labeled small bowel in formalin are fragments of tissue collectively measuring about 1 cm in greatest dimension processed entirely. One block.Part B-Received labeled gastric in formalin are fragments of tissue collecting measuring about 0.8 cm in greatest dimension processed entirely. One block. Microscopic Description:Part A-Duodenal mucosa shows an intact villous architecture without increased intraepithelial lymphocytes. No Brunner gland hyperplasia, fovelolar metaplasia, active inflammation or Giardia are identified.Part B-Gastric mucosa shows mildly reactive appearing foveolar epithelium and underlying gastric glands with lamina propria showing fibromuscular tissue with scattered chronic inflammatory cells. No intestinal metaplasia is identified.Warthin-Starry stain reveals no Helicobacter pylori forms. Pathologic Diagnosis:Part A-Small bowel, duodenum biopsy No diagnostic abnormalityPart B-Stomach, biopsyMild chronic gastritis Electronically Signed by: Peter Deutch, MD 2. What is the Primary diagnoses codes , secondary diagnosis/diagnoses in alphabetic/numeric order codes , primary procedure codes , secondary procedure(s) is numeric order codes . Include ONLY the codes. Surgical PathologyPatient Case Number: SXP04-Grier, CarolPatient Name: Carol GrierDOB: 12-22-63Sex: FSubmitting PhysicianJanet Dobson, MDAttending PhysicianSimon Powers, MDCollected Date/Time04-01-XX 10:00AMReceived Date/Time04-01-XX 10:15AMAccession Number: JP-485-7741Clinical Summary/Clinical Impression: R/O Candida Gross Description:The specimen consists of 25 ml. of hazy, colorless fluid with brush tip; two cytospin and one cell block preparation.Microscopic Description:The cytospin preparations consist of predominately many squamous cells and some fungal organisms morphologically consistent with Candida species. The cell block shows similar findings with less cellularity. Diagnosis:Esophageal brushings (cytospin and cell block preparations)No cells are diagnostic for malignancy. Some fungal organisms morphologically consistent with Candida species are present. Electronically Signed By: Sharon Walker, MD 3. What is the Primary diagnoses codes , secondary diagnosis/diagnoses in alphabetic/numeric order codes , primary procedure codes , secondary procedure(s) is numeric order codes . Include ONLY the codes. Surgical PathologyPatient Case Number: SXP07-Dubois, StephaniePatient Name: Stephanie DuboisDOB: 07-07-52Sex: FSubmitting PhysicianKeith Sims, MDAttending PhysicianNoah Burkley, MDCollected Date/Time11-19-XX 09:00AMReceived Date/Time11-19-XX 09:25AMAccession Number: LS-334-7658Clinical Summary/Clinical Impression: Hx of breast ca, R/O mets Gross Description:Received in formalin labeled “left neck lymph node” consists of multiple tan-pink to light brown soft tissue that measures approximately 1.2 x 0.8 x 0.3 cm. The entire specimen is submitted in (A1). Final DiagnosisSpecimen designated “left neck lymph node” biopsyMetastatic poorly differentiated carcinoma consistent with primary breast originThe specimen consists of multiple cores of lymph node that showed extensive infiltration by poorly differentiated malignant neoplasm. The malignant cells are arranged in the form of cords, nests, and groups of highly atypical cells with enlarged hyperchromatic nuclei. These findings support the morphologic evidence of poorly differentiated metastatic carcinoma with features consistent with invasive lobular carcinoma of the breast. Electronically Signed by: Jeremiah Singer, MD Copyright © 2020 by The American Health Information Management Association. All Rights Reserved. Health Science Science Nursing HITM 2224
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