Several months ago, the patient underwent an open cholecystectomy ...

[shofmannx20]

Several months ago, the patient underwent an open cholecystectomy for chronic cholecystitis. He subsequently developed an infection of the post-operative wound and was seen in the wound clinic for subsequent aftercare/treatment. The wound tested positive for MRSA. At the time of the current visit, the wound is continuing to heal. The wound was cleaned and addressed per protocol. The patient was instructed to continue the antibiotic treatment and to return for further cleaning and dressing of the wound in two days.
 
  Principal diagnosis: ________
   Secondary diagnoses: ________
   Principal procedure: ________
  What will be an ideal response?

Question 2

Marissa is a 24-year-old female who is 40 weeks pregnant. The pregnancy was uncomplicated. She arrived at the labor and delivery area of the hospital stating that her contractions started approximately five hours earlier and was two minutes apart at the time she arrived in L&D. Labor progressed normally and within three hours of arrival, she had an uncomplicated delivery of 6 lbs. 14.5 oz normal female.
 
  Principal Dx: ________
  Secondary diagnoses: ________
   Principal procedure: ________
  What will be an ideal response?

[pallen55]

Answer to Question 1

Principal diagnosis: ________
Answer: Aftercare following surgery on the digestive system  Z48.815

Secondary diagnoses: ________
Answer: Postoperative MRSA wound infection  T81.4XXD, B95.62

Principal procedure: ________
Answer: Abdominal wall dressing  2W23X4Z

Answer to Question 2

Principal Dx: ________
Answer: Full term, uncomplicated delivery  O80

Secondary diagnoses: ________
Answer: 39 weeks of pregnancy  Z3A.40; Z38.00  Single liveborn, vaginal delivery, in a hospital

Principal procedure: ________
Answer: Delivery  10E0XZZ