UPX Material - University of Phoenix



University of Phoenix Material

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 with history of kidney stones, urinary tract infection (UTI), and diabetes insipidus. Nursing staff reports a change in mental status, foul smelling urine, and increased incontinence with complaints of pain with urination.

On examination patient is alert. Patient notes having increased pain with urination and burning along with extreme pain in the lower abdomen at times. A urine culture was positive for e-coli bacteria. The urinalysis is positive for WBCs, RBC, and increased pH with results favorable for stone formation.

Plan to start Macrobid, increase fluid intake, repeat urinalysis and kidney function in the morning. Please catheterize the patient. Portable ultrasound in am. If positive will discuss possible cystoscopy and nephrology referral.

Impression: UTI, kidney stone

D. George, M.D.

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

|Medical term |Definition |Sources |

|1. | | |

|2. | | |

|3. | | |

|4. | | |

|5. | | |

|6. | | |

|7. | | |

|8. | | |

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|10. | | |

Part 2

Using the information in the progress note, decide which code correctly represents the diagnosis. Underline the code of your choice.

|Medical term |Medical code |

|Urinary tract infection (UTI) |N39.0 Urinary tract infection, site not specified |

| | |

| |P39.3 Urinary tract infection of newborn |

| | |

| |N99.89 Other postprocedural complications and disorders of the |

| |genitourinary system |

| | |

| |N36.9 Urethral disorder unspecified |

|Diabetes insipidus |N25.1 Nephrogenic diabetes insipidus |

| | |

| |E23.2 Diabetes insipidus |

| | |

| |P70.2 Neonatal diabetes mellitus |

| | |

| |E11.9 Diabetes mellitus without complications |

|Kidney stone |N28.1 Cyst of kidney, acquired |

| | |

| |S37.009A Injury to kidney without mention of open wound into cavity,|

| |unspecified injury, initial encounter |

| | |

| |D30.00 Benign neoplasm of kidney, unspecified kidney |

| | |

| |N20.0 Calculus of kidney |

References

Centers for Medicare & Medicaid Services (23 Oct. 2014). “ICD-10-CM Diagnosis and Procedure Codes: Abbreviated and Full Code Titles.” Retrieved from



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