Download Narrative Title - Capital Blue Cross

ICD-10 Academic Testing
Hematology-Oncology
DESTINATION 10.1.2015
Capital BlueCross is an Independent Licensee of the BlueCross BlueShield Association
Hematology-Oncology – Scenario #1
Narrative Title: ANU 1
Narrative Description: Anemia, unspecified
Patient Info:
Age: 50
Height: 62
BP: 130/78
Resp-rate: 16
Gender: Female
Weight: 120
Pulse: 72
Temp: 98.6
Chief Complaint: Patient is here for follow-up appt. for anemia
Past Med. History: Patient has a history of anemia, no other significant medical history. Patient takes Palafer CF with orange juice.
Office Visit Notes: This Patient is known to me. She was referred to me by her PCP after presenting to the office with fatigue, dizziness and shortness of breath with exertion.
A CBC found the Patient to be anemic with a Hgb. count of 9.0 g/dl. Metabolic panel and Iron studies all within normal limits. Patient denies taking any NSAIDs. Hemoccults
of the stool were negative and any other contributing factors for anemia were ruled out other than the Patient stating that she occasionally experiences heavy menstrual cycles.
She seen her OB/GYN and there weren't any significant findings. Patient is here for lab tests to check her current Hgb./Hct. to see how she is responding to medication. Results
will be called to Patient. Patient states that she has been feeling better and is less tired than she had been. She denies any shortness of breath and has resumed her normal
activities which include bike riding and exercising. Patient is making changes in diet and has been consuming more iron-rich foods. She states that she has been having
occasional bouts of constipation, but finds that eating prunes solve the problem. Additional testing may be ordered depending on CBC results.
Drugs: Palafer CF
The following ICD-9 Code(s) were chosen:
285.9
The following ICD-10 Code(s) were chosen:
D64.9
Hematology-Oncology – Scenario #2
Narrative Title: VBD-1
Narrative Description: Other vitamin B12 deficiency anemia (Vitamin B12 deficiency anemia due to
selective vitamin B12 malabsorption with proteinuria and Testicular Hypofunction)
Patient Info:
Age: 58
Height: 69
BP: 138/66
Resp-rate: 16
Gender: Male
Weight: 170
Pulse: 72
Temp: 98.6
Chief Complaint: Patient here for follow-up appt. for Vitamin B12 malabsorption with proteinuria and testosterone shot.
Past Med. History: Patient has a history of Vitamin B12 malapsorption and testicular hypofunction. He is on monthly testosterone injections of 200 mg. and 1000 mcg.
Vitamin. B12 injections.
Office Visit Notes: This Patient is known to me. Patient was referred to me about 6 months ago after a routine physical uncovered anemia with +3 protein in the urine. Further
testing uncovered Vitamin B12 deficiency anemia due to Vitamin B12 malabsorption with proteinuria. Patient is also under treatment for low testosterone levels. Patient was
given 200 mg. of testosterone IM as well as cyanocobalamin 1000 mcg. IM in 2 separate injections. Labs were drawn to check CBC, testosterone levels as well as a U/A was
obtained, that was negative for protein. Patient has been eating a diet rich in eggs, dairy and protein and states that he has been feeling great and he denies any fatigue or any
other symptoms. Patient will be contacted with lab results, will see Patient in 1 month.
Drugs: Vitamin B12, Testosterone, Cyanocobalamin
The following ICD-9 Code(s) were chosen:
281.1
The following ICD-10 Code(s) were chosen:
D51.1
Hematology-Oncology – Scenario #3
Narrative Title: TCP-1
Narrative Description: Thrombocytpenia, unspecified
Patient Info:
Age: 64
Height: 60
BP: 130/74
Resp-rate: 16
Gender: Female
Weight: 125
Pulse: 72
Temp: 98.6
Chief Complaint: Patient here for follow-up appt. for thrombocytopenia
Past Med. History: Patient has history of HTN and takes Lisinopril 20 mg. daily and also takes Crestor 10 mg. daily
Office Visit Notes: This Patient is known to me. She was referred to me by her PCP for thrombocytopenia. Her platelet count was 100,000 and was found during a routine
medical exam. She didn't have any signs of bleeding gums or petechiae, however Patient states that she bruises very easily. Patient denies alcohol use. Kidney function tests
were WNL. Patient is normally very healthy. Patient was placed on steroids and is here for a re-evaluation of blood work to evaluate results. Patient will be discontinued from
steroids if platelets WNL. Labs were drawn and Patient will be notified with results. Patient doesn't have any questions at this time.
Drugs: Lisinopril, Crestor
The following ICD-9 Code(s) were chosen:
287.5
The following ICD-10 Code(s) were chosen:
D69.6
Hematology-Oncology – Scenario #4
Narrative Title: PHC-1
Narrative Description: Primary hypercoagulable state (Antiphospholipid syndrome)
Patient Info:
Age: 39
Height: 68
BP: 130/72
Resp-rate: 16
Gender: Female
Weight: 150
Pulse: 72
Temp: 98.6
Chief Complaint: Patient was referred for primary hypercoagulable state
Past Med. History: Patient has history of 4 miscarriages and migraines
Office Visit Notes: This is a new Patient. She was referred to me by her OB/GYN. She has a history of migraines and has also suffered 4 miscarriages. She did have one live
birth about 3 weeks ago, but had complications during her pregnancy. She developed a blood clot and also suffered from preeclampsia. After initial treatment with IV Heparin,
Patient was placed on Lovenox throughout pregnancy. PCP suspected primary hypercoagulable state and labs were drawn for Lupus anticoagulant, Anti-cardiolipin and Beta-2
glycoprotein I (B2GPI). Patient tested negative for lupus and anti-cardiolipin, but antibodies were present for B2GPI. Patient has no evidence of infection and is unaware of any
family history of coagulation disorders. Upon further investigation, Patient admits to heavy menstrual periods and nosebleeds. Patient doesn't have any evidence of petecchiae,
pedal edema or redness or warmth of extremities. Patient noticed that she hasn't had any headaches since being treated with Heparin and then Lovenox. Based on test results
and patient's history of symptoms, impression is antiphospholipid syndrome. Will repeat blood tests in 12 weeks to verify presence of antibodies. In the mean time, Patient was
placed on Coumadin 5 mg. with the goal of an (INR) of 2.0 to 3.0. Will check INR in 1 week and adjust dosage prn. Patient was given information on condition and
understands goal of treatment and side effects of Coumadin to watch for. Patient also knows food to avoid while on anti-coagulant therapy.
Drugs: Heparin, Lovenox, Coumadin
The following ICD-9 Code(s) were chosen:
289.81
The following ICD-10 Code(s) were chosen:
D68.61
Hematology-Oncology – Scenario #5
Narrative Title: NPU-1
Narrative Description: Neutropenia, unspecified
Patient Info:
Age: 59
Height: 70
BP: 128/74
Resp-rate: 16
Gender: Male
Weight: 190
Pulse: 72
Temp: 98.6
Chief Complaint: Patient here for follow-up appointment for Neutropenia.
Past Med. History: Patient takes Folic Acid daily.
Office Visit Notes: This Patient is known to me. He is under treatment for neutropenia. He was originally seen by his PCP for an oral thrush infection. When lab work was
drawn, he had a WBC (white blood cells) of 2000 cells per microliter and an ANC (absolute neutrophil count) of 1400/microL. Testing was done, including a bone marrow
biopsy, and was unable to find any medical reason for neutropenia, other than Patient being of Jewish descent. Patient's last WBC was 2500, so it was decided to not treat with
medications other than Folic Acid at this time unless WBC rate falls, then will treat with Neupogen. Labs were drawn today and Patient will be called with results. Patient is
aware of instructions to prevent infection that includes hand washing and avoidance of people who are ill. Also advised Patient of the following: to avoid raw and undercooked
meat or well water, commercial fruit juices, beer, milk, and milk products should be pasteurized, aged cheese and cheese-based dressings should not be used, avoid unwashed
raw fruits and vegetables; these may contain large numbers of bacteria. All food should be cooked. Fresh flowers should be avoided as well. Patient understands all instructions
and will return to the office for his next scheduled blood draw.
Drugs: Folic Acid, Lisinopril
The following ICD-9 Code(s) were chosen:
288
The following ICD-10 Code(s) were chosen:
D70.9
Hematology-Oncology – Scenario #6
Narrative Title: OML-1
Narrative Description: Other malignant lymphomas, unspecified site, extranodal and solid organ sites
(Non-Hodgkin lymphoma, unspecified, extranodal and solid organ sites)
Patient Info:
Age: 79
Height: 66
BP: 140/78
Resp-rate: 20
Gender: Male
Weight: 132
Pulse: 71
Temp: 98.6
Chief Complaint: Patient is here for follow-up visit for Non-Hodgkin lymphoma.
Past Med. History: Patient has history of HTN and takes Lisinopril 30 mg. daily
Office Visit Notes: This Patient is known to me. Patient was referred to me by his PCP. He had complaints of fatigue, weight loss, itchy skin and night sweats for about 1 month.
He also stated that it seemed like his abdomen was swollen. An exam showed swollen painless lymph nodes in the abdomen. A complete work-up was done, including blood
chemistry, PET scan and Chest X-ray by this office. An incisional biopsy was done and it confirmed Non-Hodgkin lymphoma. Based on PET scan, the disease involves the
spleen, pancreas and surrounding lymph nodes and extranodal localization in the gastrointestinal (GI) tract. A bone marrow aspiration and biopsy from the hip bone was done
under local anesthetic in the office today to stage the disease and to also determine if it's involving the bone marrow. Patient tolerated the procedure well. He was accompanied
by his wife and daughter. After the procedure, it was explained that his case would be presented to the tumor board once the bone marrow results return. Based on the
recommendations, therapy will begin. Patient and family understand the next steps and will be contacted when the results of the bone marrow come in and when the tumor board
will meet. Patient and family given educational information to review and do not have any questions at this time.
Drugs: Lisinopril
The following ICD-9 Code(s) were chosen:
202.83
The following ICD-10 Code(s) were chosen:
C85.93
Hematology-Oncology – Scenario #7
Narrative Title: MMN-1
Narrative Description: Multiple myeloma w/o mention of having achieved remission
Patient Info:
Age: 41
Height: 70
BP: 130/72
Resp-rate: 18
Gender: Male
Weight: 174
Pulse: 72
Temp: 98.6
Chief Complaint: Patient here for follow-up appt. to discuss test results
Past Med. History: Patient has a history of HTN and takes Cardizem 25 mg. twice daily and Crestor 10 mg. for high cholesterol.
Office Visit Notes: This Patient is known to me. He was referred to me by his PCP after complaints of weakness, fatigue and bone pain. Multiple tests confirmed multiple
myeloma and he is currently under treatment. He presented to the office today for administration of bortezomib, 0.1 mg intravenously, via PICC line. Patient tolerated
procedure well and PICC line was flushed with saline followed by Heparin. Labs were drawn and Patient will be contacted with results. Patient denies any untoward side
effects currently and will return to have next dose of medication. Patient has no questions at this time.
Drugs: Bortezomib, Lenalidomide, Dexamethasone, Heparin
The following ICD-9 Code(s) were chosen:
203
The following ICD-10 Code(s) were chosen:
C90.00
Hematology-Oncology – Scenario #8
Narrative Title: CLN-1
Narrative Description: Chronic lymphoid leukemia w/o mention of having achieved remission
(Chronic lymphocytic leukemia of B-cell type not having achieved remission)
Patient Info:
Age: 83
Height: 63
BP: 138/74
Resp-rate: 18
Gender: Male
Weight: 125
Pulse: 70
Temp: 98.6
Chief Complaint: Patient has a history of HTN and takes Cardizem 25 mg. twice daily and Crestor 10 mg. for high cholesterol
Past Med. History: Patient has a history of multiple myeloma and takes bortezomib, 0.1 mg. lenalidomide 25 mg., and dexamethasone 20 mg.
Office Visit Notes: This Patient is known to me. He was referred to me by his PCP after being seen for complaints of fatigue, night sweats and weight loss. A CBC was done
and there were a high number of B cells. Additional tests, including CT scan and bone marrow aspiration and biopsy were done to confirm the diagnosis of CLL of B-cell type.
The cancer was found to be in its very earliest stage. Patient was accompanied by his daughter and son and treatment options were presented to Patient and family. Based on
the patient's age and the fact that Patient is unsure of what he wants to do, it was decided to delay treatment. Patient was advised to be careful to avoid infection, to eat a diet
rich in fruits and vegetables and to make sure that he makes it to all of his Doctor appointments to monitor progression of his chronic lymphoid leukemia. Family understands
plan of care and were given education materials to review. Patient to follow-up in the office in 1 month.
Drugs: Cardizem, Crestor
The following ICD-9 Code(s) were chosen:
204.1
The following ICD-10 Code(s) were chosen:
C90.00
Hematology-Oncology – Scenario #9
Narrative Title: MMR-1
Narrative Description: Multiple myeloma in remission
Patient Info:
Age: 53
Height: 63
BP: 138/74
Resp-rate: 18
Gender: Female
Weight: 141
Pulse: 70
Temp: 98.6
Chief Complaint: Patient is here for follow-up visit for multiple myeloma
Past Med. History: Patient has history of multiple myeloma, but is currently not on any medications other than an OTC MVI and Calcium supplement.
Office Visit Notes: This Patient is known to me. Patient is here for a check-up for her multiple myeloma that is currently in remission. Her last test results showed no
detectable monoclonal protein and the number of plasma cells in the bone marrow was normal (less than 5%). Patient was treated with vincristine, Adriamycin/doxorubicin and
dexamethasone and had an autologous stem cell transplant. She currently has been in remission for 3 months. Labs were drawn and Patient will be notified of results. Patient
states that she has been feeling pretty well and that her energy is returning. She has some occasional aches and pains, but she states that it's "bearable". Discussed that will
continue to monitor lab values and based on symptoms and/or lab results, a bone marrow aspiration and biopsy may be done in the future. Patient understands plan and has no
questions at this time. Patient to follow-up in office in 3 months or sooner, depending on lab results.
Drugs: None
The following ICD-9 Code(s) were chosen:
203.01
The following ICD-10 Code(s) were chosen:
C90.01
Hematology-Oncology – Scenario #10
Narrative Title: AMN-1
Narrative Description: Acute meyloid leukemia w/o mention of having achieved remission
(Acute myelomonocytic leukemia, not having achieved remission)
Patient Info:
Age: 38
Height: 66
BP: 120/78
Resp-rate: 18
Gender: Female
Weight: 138
Pulse: 71
Temp: 98.6
Chief Complaint: Patient here for lab work for acute myelomoncytic leukemia
Past Med. History: Patient has no significant medical history other than leukemia. She is on daunorubicin and ara-C intravenously on an outpatient basis and oral Zofran ODT
8 mg. twice daily for nausea as needed.
Office Visit Notes: This Patient is known to me. She was originally referred to me by her PCP for fatigue, night sweats and petecchiae. PCP palpated an enlarged spleen.
Blood tests showed reduced RBC's and platelets. Multiple tests, including bone marrow aspiration and biopsy were done by this office and results showed a diagnosis of acute
melomonocytic leukemia. Patient is in the midst of 7 + 3 induction treatment using daunorubicin and ara-C via mediport, she is here today for routine lab work and assessment
for chemo side effects. Patient states that she has been losing some hair and experiences a moderate amount of nausea and vomiting the 24 hours following the chemo. She
denies any diarrhea, skin rash or dizziness. She states that she is having some mild hair loss. Advised Patient to make sure that she takes her anti-nausea medication in advance
and not to wait until nausea is too far advanced, avoid strong odors, to eat things like crackers/dry toast and to drink plenty of fluids, keep head elevated 2 hours after eating.
Also, if vomiting, to only sip clear liquids and then advance to things like bread, rice and toast. Patient is taking ondansetron for the nausea, but admits that she's waiting too
long to take it. Patient will be called with lab results and notified if any measures need to be taken based on results. Patient understands treatment plan and has no questions at
this time. Patient information was given to Patient for review regarding chemotherapy side effects and management. Advised Patient that if she is unable to tolerate oral antiemetic or if severe nausea to notify office or call after hours number.
Drugs: Daunorubicin, Zofran, ara-C, Ondansetron
The following ICD-9 Code(s) were chosen:
205
The following ICD-10 Code(s) were chosen:
C92.90
Hematology-Oncology – Scenario #11
Narrative Title: NLM-1
Narrative Description: Nodular lymphoma, lymph nodes of multiple sites
(Follicular lymphoma grade IIIb, lymph nodes of multiple sites)
Patient Info:
Age: 58
Height: 64
BP: 128/76
Resp-rate: 16
Gender: Female
Weight: 150
Pulse: 72
Temp: 98.6
Chief Complaint: Patient here for lab work and check-up for follicular lymphoma.
Past Med. History: Patient is currently under treatment for follicular lymphoma and is on Rituximab 375 mg/m2 (day 1) plus Bendamustine 90 mg/m2 (days 1+2) every 28
days for six cycles. Patient has completed three cycles so far.
Office Visit Notes: This Patient is known to me. She was originally referred to me by her PCP after a routine physical showed swollen lymph nodes above and below the
diaphragm and splenomegaly. Upon further questioning, Patient stated that she was experiencing excessive night sweating and fatigue, but she had attributed it to menopausal
changes. Patient also had lost 10 pounds since her last office visit. Multiple tests were done by this office, including lymph node biopsy, bone marrow aspiration and biopsy
and CT scan. Patient was found to have Follicular lymphoma grade IIIb. Treatment options, including radiotherapy, chemotherapy and monclonal antibodies were discussed
with the Patient. After discussion with Patient and family, it was agreed to treat Patient with Rituximab 375 mg/m2 (day 1) plus Bendamustine 90 mg/m2 (days 1+2) every 28
days for six cycles. Patient has completed 3 cycles so far. Patient denies any neuropathy, alopecia or mouth sores or rash. Explained to Patient sign/symptoms to watch for,
including skin rash, stomatitis and given pamphlet of information to review at home. Labs were drawn and Patient will be notified with results. Upon examination lymph nodes
seem to be shrinking in size. Lungs are clear and all vital signs are WNL. Will follow-up with Patient with labs and provide additional treatment, depending on results.
Drugs: Rituximab, Bendamustine
The following ICD-9 Code(s) were chosen:
202.08
The following ICD-10 Code(s) were chosen:
C85.89
Hematology-Oncology – Scenario #12
Narrative Title: HDU-1
Narrative Description: Hodgkin's disease, unspecified
(Hodgkin lymphoma, unspecified, extranodal and solid organ sites)
Patient Info:
Age: 25
Height: 68
BP: 110/70
Resp-rate: 18
Gender: Female
Weight: 132
Pulse: 72
Temp: 98.6
Chief Complaint: Patient here to discuss test results from last visit after complaints of night sweats, fatigue, itching and swollen lymph nodes in the neck and under her arms.
Past Med. History: Patient has no significant medical history and is current on all immunizations.
Office Visit Notes: This Patient is known to me. She was referred to me by her PCP after being seen for complaints of night sweats, fatigue, itching and swollen lymph nodes
in the neck and under her arms. Her PCP found her spleen and right kidney to be enlarged. Based on PET scan, the disease involves the spleen, kidney and surrounding lymph
nodes. Extranodal localization in the gastrointestinal (GI) tract was also noted. This office performed bone marrow aspiration and was sent out for analysis. The results of the
biopsy of the spleen and kidney and surrounding lymph tissue were positive for Hodgkin’s lymphoma. Patient and family are here today to discuss test results. Diagnosis and
potential treatment options were explained to Patient and family. The plan is to meet with the tumor board to discuss all test results and agree on the best course of treatment.
Further explained that treatment could consist of a combination of chemotherapy, radiation therapy and stem cell transplant or enrollment in a clinical trial. Patient education
materials were given to Patient and family and they were encouraged to read the information and to write down any questions that they may have and bring to the next office
visit. Patient is to have PFT and MUGA scan tomorrow to determine baseline functions when considering treatment options. Patient will follow-up in the office next week to
discuss treatment.
Drugs: None
The following ICD-9 Code(s) were chosen:
201.9
The following ICD-10 Code(s) were chosen:
C81.99
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