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NR511 Midterm Exam Study Guide - complete Solution Already Graded A.

NR511 Midterm Exam Study Guide - complete Solution Already Graded A.
NR511 Midterm Exam Study Guide - complete Solution Already Graded A.
NR511 Midterm Exam Study Guide - complete Solution Already Graded A.
NR511 Midterm Exam Study Guide - complete Solution Already Graded A.
NR511 Midterm Exam Study Guide Week 1 1. Define diagnostic reasoning 2. Discuss and identify subjective & objective data 3. Discuss and identify the components of the HPI 4. Describe the differences between medical billing and medical coding 5. Compare and contrast the 2 coding classification systems that are currently used in the US healthcare system 6. Discuss how specificity, sensitivity & predictive value contribute to the usefulness of the diagnostic data 7. Discuss the elements that need to be considered when developing a plan 8. Describe the components of Medical Decision Making in E&M coding 9. Correctly order the E&M office visit codes based on complexity from least to most complex 10. Discuss a minimum of three purposes of the written history and physical in relation to the importance of documentation 11. Accurately document why every procedure code must have a corresponding diagnosis code 12. Correctly identify a patient as new or established given the historical information 13. Identify the 3 components required in determining an outpatient, office visit E&M code 14. Describe the components of Medical Decision Making in E&M coding 15. Correctly order the E&M office visit codes based on complexity from least to most complex 16. Explain what a “well rounded” clinical experience means 17. State the maximum number of hours that time can be spent “rounding” in a facility 18. State 9 things that must be documented when inputting data into clinical encounter 19. Identify and explain each part of the acronym SNAPPS Week 2 1. Identify the most common type of pathogen responsible for acute gastroenteritis 2. Recognize that assessing for prior antibiotic use is a critical part of the history in patients presenting with diarrhea 3. Describe the difference between Irritable Bowel Disease (IBS) and Inflammatory Bowel Disorder (IBD) IBS Inflammatory Bowel Disorder (IBD) ● A chronic immunological disease that manifests in intestinal inflammation. ● Characterized by exacerbations and remissions throughout lifetime. ● UC and CD -- most common 4. Discuss two common Inflammatory Bowel Diseases Ulcerative colitis (UC): ● the thinner mucosa of the rectum and sigmoid colon become inflamed, which results in friability, erosions, and bleeding. ● More in male (age 10-40) ● Involved in the rectosigmoid areas, crypt abscess development ● Sx: bleeding, cramping, urge to defecate d/t mucosa destruction ● Tenderness LLQ or across the entire abdomen, often accompanied by guarding and abdo distension; ● Stools --watery diarrhea w/ blood and mucus d/t loss of absorptive surface ○ Fecal leukocytes almost always present ○ Mild form < 4 BM per day, relieved w/defecation, no associated systemic sx ○ Moderate (4-6 BM/day), ↑ blood and mucus, systemic sx (tachy, fever, wt loss) ○ Severe -- (6-10/day), abdo tenderness, symptoms of anemia, hypovolemia, and impaired nutrition, --risk for perf colon Crohn’s disease (CD): ● An inflammatory process that begins in the submucosa of the intestine and gradually spreads to involve the mucosa and serosa. ● Can involve all or any layer of the bowel wall and portion of GI tract from mouth to anus (about 80% small bowel involvement and 20% of the colon). ● More in female (age 15-25, 50-80) ● Greater risk for colorectal cancer ● Skipped lesions --some haustral segments are affected while others are not. ● cobblestone appearance--inflamed tissue is surrounded by scar tissue. ● Transmural inflammation -- serosal inflammation cause bowel loops to adhere to one another leads to obstruction, fistulas, and shortening of the bowel. ● Tenderness RLQ or mass ● Sx: abdo cramping, fever, anorexia, weight loss, spasm, flatulence, ● Stools contain blood, mucus, and/or pus ● Symptoms tend to increase during stress or after meals consisting of poorly tolerated fatty, spicy, or dairy. ● Steatorrhea- fatty stools d/t insufficient absorption of bile salt ● 5. Discuss the diagnosis of diverticulitis, risk factors, and treatments - Diagnosis = occurs when a patient’s diverticulosis becomes inflamed and when the projection becomes eroded it can progress to the point of eruption causing left lower quad pain and tenderness, fever, change in bowel habits (usually diarrhea), N/V, mass, rebound tenderness with involuntary guarding and rigidity, occult blood. If there is a fistula, UA may show increased WBC and RBC, urine culture may be positive. - Risk Factors = low fiber diet, hypertrophy of the segments of the circular muscle of the colon, chronic constipation and straining, irregular and uncoordinated bowel contractions, obesity, and weakness of the bowel muscle brought on by aging. Directly related to the suspected causes of the disease: older than age 40, low-fiber diet, previous diverticulitis, and the number of diverticula present in the colon.

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