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Answer to part 1, answer to part 2, answer to part 3, answer to part 4, answer to part 5.

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Educational Case: A 57-year-old man with chest pain

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Nikhil Aggarwal, Subothini Selvendran, Vassilios Vassiliou, Educational Case: A 57-year-old man with chest pain, Oxford Medical Case Reports , Volume 2016, Issue 4, April 2016, Pages 62–65, https://doi.org/10.1093/omcr/omw008

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This is an educational case report including multiple choice questions and their answers. For the best educational experience we recommend the interactive web version of the exercise which is available via the following link: http://www.oxfordjournals.org/our_journals/omcr/ec01p1.html

A 57 year-old male lorry driver, presented to his local emergency department with a 20-minute episode of diaphoresis and chest pain. The chest pain was central, radiating to the left arm and crushing in nature. The pain settled promptly following 300 mg aspirin orally and 800 mcg glyceryl trinitrate (GTN) spray sublingually administered by paramedics in the community. He smoked 20 cigarettes daily (38 pack years) but was not aware of any other cardiovascular risk factors. On examination he appeared comfortable and was able to complete sentences fully. There were no heart murmurs present on cardiac auscultation. Blood pressure was 180/105 mmHg, heart rate was 83 bpm and regular, oxygen saturation was 97%.

What is the most likely diagnosis?

An ECG was requested and is shown in figure 1.

How would you manage the patient? (The patient has already received 300 mg aspirin).

30 minutes later the patient's chest pain returned with greater intensity whilst waiting in the emergency department. Now, he described the pain as though “an elephant is sitting on his chest”. The nurse has already done an ECG by the time you were called to see him. This is shown in figure 2.

ECG on admission.

ECG 30 minutes after admission.

What would be the optimal management for this patient?

He was taken to the catheterization lab where the left anterior descending coronary artery (LAD) was shown to be completely occluded. Following successful percutaneous intervention and one drug eluding stent implantation in the LAD normal flow is restored (Thrombosis in myocardial infarction, TIMI = 3). 72 hours later, he is ready to be discharged home. The patient is keen to return to work and asks when he could do so.

When would you advise him that he could return to work?

One week later, he receives a letter informing him that he is required to attend cardiac rehabilitation. The patient is confused as to what cardiac rehabilitation entails, although he does remember a nurse discussing this with him briefly before he was discharged. He phones the hospital in order to get some more information.

Which of the following can be addressed during cardiac rehabilitation?

A - Acute coronary syndrome

Although the presentation could be attributable to any of the above differential diagnoses, the most likely etiology given the clinical picture and risk factors is one of cardiac ischemia. Risk factors include gender, smoking status and age making the diagnosis of acute coronary syndrome the most likely one. The broad differential diagnosis in patients presenting with chest pain has been discussed extensively in the medical literature. An old but relevant review can be found freely available 1 as well as more recent reviews. 2 , 3

C - Atorvastatin 80 mg, Clopidogrel 300 mcg, GTN 500 mcg, Ramipril 2.5 mg,

In patients with ACS, medications can be tailored to the individual patient. Some medications have symptomatic benefit but some also have prognostic benefit. Aspirin 4 , Clopidogrel 5 , Atenolol 6 and Atorvastatin 7 have been found to improve prognosis significantly. ACE inhibitors have also been found to improve left ventricular modeling and function after an MI. 8 , 9 Furthermore, GTN 10 and morphine 11 have been found to be of only significant symptomatic benefit.

Oxygen should only to be used when saturations <95% and at the lowest concentration required to keep saturations >95%. 12

There is no evidence that diltiazem, a calcium channel blocker, is of benefit. 13

His ECG in figure 1 does not fulfil ST elevation myocardial infarction (STEMI) criteria and he should therefore be managed as a Non-STEMI. He would benefit prognostically from beta-blockade however his heart rate is only 42 bpm and therefore this is contraindicated. He should receive a loading dose of clopidogrel (300 mg) followed by daily maintenance dose (75 mg). 14 , 15 He might not require GTN if he is pain-free but out of the available answers 3 is the most correct.

D - Proceed to coronary angiography

The ECG shows ST elevation in leads V2-V6 and confirms an anterolateral STEMI, which suggests a completely occluded LAD. This ECG fulfils the criteria to initiate reperfusion therapy which traditionally require one of the three to be present: According to guidance, if the patient can undergo coronary angiography within 120 minutes from the onset of chest pain, then this represents the optimal management. If it is not possible to undergo coronary angiography and potentially percutaneous intervention within 2 hours, then thrombolysis is considered an acceptable alternative. 12 , 16

≥ 1 mm of ST change in at least two contiguous limb leads (II, III, AVF, I, AVL).

≥ 2 mm of ST change in at least two contiguous chest leads (V1-V6).

New left bundle branch block.

GTN and morphine administration can be considered in parallel but they do not have a prognostic benefit.

E - Not before an exercise test

This patient is a lorry driver and therefore has a professional heavy vehicle driving license. The regulation for driving initiation in a lorry driver following a NSTEMI/ STEMI may be different in various countries and therefore the local regulations should be followed.

In the UK, a lorry driver holds a category 2 driving license. He should therefore refrain from driving a lorry for at least 6 weeks and can only return to driving if he completes successfully an exercise evaluation. An exercise evaluation is performed on a bicycle or treadmill. Drivers should be able to complete 3 stages of the standard Bruce protocol 17 or equivalent (e.g. Myocardial perfusion scan) safely, having refrained from taking anti-anginal medication for 48 hours and should remain free from signs of cardiovascular dysfunction during the test, notably: angina pectoris, syncope, hypotension, sustained ventricular tachycardia, and/or electrocardiographic ST segment shift which is considered as being indicative of myocardial ischemia (usually >2 mm horizontal or down-sloping) during exercise or the recovery period. 18

For a standard car driving license (category 1), driving can resume one week after successful intervention providing that no other revascularization is planned within 4 weeks; left ventricular ejection fraction (LVEF) is at least 40% prior to hospital discharge and there is no other disqualifying condition.

Therefore if this patent was in the UK, he could restart driving a normal car one week later assuming an echocardiogram confirmed an EF > 40%. However, he could only continue lorry driving once he has passed the required tests. 18

E - All of the above

Cardiac rehabilitation bridges the gap between hospitals and patients' homes. The cardiac rehabilitation team consists of various healthcare professions and the programme is started during hospital admission or after diagnosis. Its aim is to educate patients about their cardiac condition in order to help them adopt a healthier lifestyle. This includes educating patients' about their diet, exercise, risk factors associated with their condition such as smoking and alcohol intake and finally, about the medication recommended. There is good evidence that adherence to cardiac rehabilitation programmes improves survival and leads to a reduction in future cardiovascular events.​ 19 , 20

Oille JA . Differential diagnosis of pain in the chest . Can Med Assoc J . 1937 ; 37 (3) : 209 – 216 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC536075/ .

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Lee TH , Goldman L . Evaluation of the patient with acute chest pain . N Engl J Med . 2000 ; 342 (16) : 1187 – 1195 . http://www.nejm.org/doi/full/10.1056/NEJM200004203421607 .

Douglas PS , Ginsburg GS . The evaluation of chest pain in women . N Engl J Med . 1996 ; 334 (20) : 1311 – 1315 . http://www.nejm.org/doi/full/10.1056/NEJM199605163342007 .

Baigent C , Collins R , Appleby P , Parish S , Sleight P , Peto R . ISIS-2: 10 year survival among patients with suspected acute myocardial infarction in randomised comparison of intravenous streptokinase, oral aspirin, both, or neither. the ISIS-2 (second international study of infarct survival) collaborative group . BMJ . 1998 ; 316 (7141) : 1337 – 1343 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC28530/ .

Yusuf S , Zhao F , Mehta S , Chrolavicius S , Tognoni G , Fox K . Clopidogrel in unstable angina to prevent recurrent events trail investigators . effects of clopidogrel in addition to aspirin in patients with acute coronary syndromes without ST-segment elevation . N Engl J Med . 2001 ; 345 (7) : 494 – 502 . http://www.nejm.org/doi/full/10.1056/NEJMoa010746#t=articleTop .

Yusuf S , Peto R , Lewis J , Collins R , Sleight P . Beta blockade during and after myocardial infarction: An overview of the randomized trials . Prog Cardiovasc Dis . 1985 ; 27 (5) : 335 – 371 . http://www.sciencedirect.com/science/article/pii/S0033062085800037 .

Schwartz GG , Olsson AG , Ezekowitz MD et al.  . Effects of atorvastatin on early recurrent ischemic events in acute coronary syndromes: The MIRACL study: A randomized controlled trial . JAMA . 2001 ; 285 (13) : 1711 – 1718 . http://jama.jamanetwork.com/article.aspx?articleid=193709 .

Pfeffer MA , Lamas GA , Vaughan DE , Parisi AF , Braunwald E . Effect of captopril on progressive ventricular dilatation after anterior myocardial infarction . N Engl J Med . 1988 ; 319 (2) : 80 – 86 . http://content.onlinejacc.org/article.aspx?articleid=1118054 .

Sharpe N , Smith H , Murphy J , Hannan S . Treatment of patients with symptomless left ventricular dysfunction after myocardial infarction . The Lancet . 1988 ; 331 (8580) : 255 – 259 . http://www.sciencedirect.com/science/article/pii/S0140673688903479 .

Ferreira JC , Mochly-Rosen D . Nitroglycerin use in myocardial infarction patients . Circ J . 2012 ; 76 (1) : 15 – 21 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3527093/ .

Herlitz J , Hjalmarson A , Waagstein F . Treatment of pain in acute myocardial infarction . Br Heart J . 1989 ; 61 (1) : 9 – 13 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1216614/ .

Task Force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC), Steg PG, James SK, et al . ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation . Eur Heart J . 2012 ; 33 (20) : 2569 – 2619 . http://eurheartj.oxfordjournals.org/content/33/20/2569 .

The effect of diltiazem on mortality and reinfarction after myocardial infarction . the multicenter diltiazem postinfarction trial research group . N Engl J Med . 1988 ; 319 (7) : 385 – 392 . http://www.nejm.org/doi/full/10.1056/NEJM198808183190701 .

Jneid H , Anderson JL , Wright RS et al.  . 2012 ACCF/AHA focused update of the guideline for the management of patients with unstable angina/Non–ST-elevation myocardial infarction (updating the 2007 guideline and replacing the 2011 focused update) A report of the american college of cardiology foundation/american heart association task force on practice guidelines . J Am Coll Cardiol . 2012 ; 60 (7) : 645 – 681 . http://circ.ahajournals.org/content/123/18/2022.full .

Hamm CW , Bassand JP , Agewall S et al.  . ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation: The task force for the management of acute coronary syndromes (ACS) in patients presenting without persistent ST-segment elevation of the european society of cardiology (ESC) . Eur Heart J . 2011 ; 32 (23) : 2999 – 3054 . http://eurheartj.oxfordjournals.org/content/32/23/2999.long .

O'Gara PT , Kushner FG , Ascheim DD et al.  . 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: Executive summary: A report of the american college of cardiology foundation/american heart association task force on practice guidelines . J Am Coll Cardiol . 2013 ; 61 (4) : 485 – 510 . http://content.onlinejacc.org/article.aspx?articleid=1486115 .

BRUCE RA , LOVEJOY FW Jr . Normal respiratory and circulatory pathways of adaptation in exercise . J Clin Invest . 1949 ; 28 (6 Pt 2) : 1423 – 1430 . http://www.ncbi.nlm.nih.gov/pmc/articles/PMC439698/ .

DVLA . Https://Www.gov.uk/current-medical-guidelines-dvla-guidance-for-professionals-cardiovascular-chapter-appendix .

British Heart Foundation . Http://Www.bhf.org.uk/heart-health/living-with-heart-disease/cardiac-rehabilitation.aspx .

Kwan G , Balady GJ . Cardiac rehabilitation 2012: Advancing the field through emerging science . Circulation . 2012 ; 125 (7) : e369–73. http://circ.ahajournals.org/content/125/7/e369.full .

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You need to understand the case as a whole to avoid fixating on single pieces of information that lead to a wrong answer choice.

Question writers know that because of the length of the questions, candidates do not want to read the whole question if they can help it. They know that some test takers are scanning for that one critical piece of information. Because of this, single pieces of information may lead you away from the right answer to one of the incorrect distractors. Avoid this trap. You need to focus on the meaning of the case as a whole, not any one piece of it.

Clincal Case Practice Question 1

A 24-year-old woman presents with a fever and myalgias. She experienced brief, self-limited diarrhea 24 hours after attending a barbecue two weeks earlier. She remained asymptomatic until the day prior to presentation when she developed a fever of 39.4 C (103 F), conjunctivitis, and severe muscle pain. On physical examination she appears acutely ill and has a fever of 39.4 C. There is a diffuse maculopapular rash and generalized muscular tenderness. Several hemorrhages are noted beneath the fingernails. Admission hemogram reveals a white blood cell count of 15,000/mm3 with 25 percent eosinophils. The infectious form of the most likely causative agent is a(n) (A) cyst (B) cysticerci (C) encysted larvae (D) ovum (E) rhabditiform larvae

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The correct answer is C, encysted larvae.

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A pair of brothers (35 and 38 years old) present with fairly dramatic pneumonias. On lung exam, rales are easily heard. Chest x-rays of both men reveal bilateral and diffuse infiltrates. The brothers spent a day together two weeks ago hiking in a mountainous area of Virginia where they entered a dusty cave. The most likely causative agent is (A) Blastomyces dermatitidis (B) Chlamydia trachomatis (C) Coccidioides immitis (D) Coxsackie A virus (E) Haemophilus ducreyi (F) Haemophilus influenzae (G) Histoplasma capsulatum (H) Influenza B virus (I) Neisseria gonorrhoeae (J) Neisseria meningitidis (K) Streptococcus pyogenes

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Chapter 7:  10 Real Cases on Transient Ischemic Attack and Stroke: Diagnosis, Management, and Follow-Up

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Case 1: Management of Acute Thrombotic Cerebrovascular Accident Post Recombinant Tissue Plasminogen Activator Therapy

A 59-year-old Hispanic man presented with right upper and lower extremity weakness, associated with facial drop and slurred speech starting 2 hours before the presentation. He denied visual disturbance, headache, chest pain, palpitations, dyspnea, dysphagia, fever, dizziness, loss of consciousness, bowel or urinary incontinence, or trauma. His medical history was significant for uncontrolled type 2 diabetes mellitus, hypertension, hyperlipidemia, and benign prostatic hypertrophy. Social history included cigarette smoking (1 pack per day for 20 years) and alcohol intake of 3 to 4 beers daily. Family history was not significant, and he did not remember his medications. In the emergency department, his vital signs were stable. His physical examination was remarkable for right-sided facial droop, dysarthria, and right-sided hemiplegia. The rest of the examination findings were insignificant. His National Institutes of Health Stroke Scale (NIHSS) score was calculated as 7. Initial CT angiogram of head and neck reported no acute intracranial findings. The neurology team was consulted, and intravenous recombinant tissue plasminogen activator (t-PA) was administered along with high-intensity statin therapy. The patient was admitted to the intensive care unit where his hemodynamics were monitored for 24 hours and later transferred to the telemetry unit. MRI of the head revealed an acute 1.7-cm infarct of the left periventricular white matter and posterior left basal ganglia. How would you manage this case?

This case scenario presents a patient with acute ischemic cerebrovascular accident (CVA) requiring intravenous t-PA. Diagnosis was based on clinical neurologic symptoms and an NIHSS score of 7 and was later confirmed by neuroimaging. He had multiple comorbidities, including hypertension, diabetes, dyslipidemia, and smoking history, which put him at a higher risk for developing cardiovascular disease. Because his symptoms started within 4.5 hours of presentation, he was deemed to be a candidate for thrombolytics. The eligibility time line is estimated either by self-report or last witness of baseline status.

Ischemic strokes are caused by an obstruction of a blood vessel, which irrigates the brain mainly secondary to the development of atherosclerotic changes, leading to cerebral thrombosis and embolism. Diagnosis is made based on presenting symptoms and CT/MRI of the head, and the treatment is focused on cerebral reperfusion based on eligibility criteria and timing of presentation.

Symptoms include alteration of sensorium, numbness, decreased motor strength, facial drop, dysarthria, ataxia, visual disturbance, dizziness, and headache.

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Internal Medicine Cases & Quizzes

• Fast Five Quiz: Hiding in the Mediterranean Diet Are you aware of some of the less recognized aspects of the Mediterranean diet? Test yourself with this short quiz. Medscape , September 10, 2024
• A 17-Year-Old With a Vacation Rash The rash is in both armpits and his groin. Medscape , September 09, 2024
• Fast Five Quiz: Common Back-to-School Concerns Are you aware of which illnesses and issues are most common in school-aged children returning to the classroom? Test yourself with this short quiz. Medscape , September 06, 2024
• Fast Five Quiz: Alzheimer's Disease Variants Can you recognize and manage Alzheimer's disease variants? Test your knowledge with this quick quiz. Medscape , September 06, 2024
• Fast Five Quiz: MASLD and MASH Complications Do you know what complications to look for in patients with MASLD and MASH? Check your knowledge with this quick quiz. Medscape , September 06, 2024
• Breast Cancer e-Tumor Boards: Case 6: ER+ mBC with BRAF V600E Mutation   This case focuses on a 49-year-old woman with HR+ metastatic breast cancer referred to the tumor board due to BRAF V600 mutation. The panel discusses optimal treatment approaches for bone metastases and epidural compression. Medscape , September 05, 2024
• Stroke-Like Episodes While Drinking Alcohol The patient reports three episodes of slurred speech and right arm weakness. Medscape , September 05, 2024
• Fast Five Quiz: Indolent Systemic Mastocytosis How much do you know about indolent systemic mastocytosis? Test your knowledge with this quick quiz. Medscape , September 05, 2024
• Excessive Bleeding After Dental Procedure A 57-year-old man presents with excessive bleeding that won't stop after a dental cleaning procedure. He had a fever 4-5 days earlier but describes no other symptoms. What's the diagnosis? Medscape , September 05, 2024
• Rapid Rx Quiz: Most Effective Obesity Drugs Do you know what to prescribe for patients who are struggling with weight loss? Test your knowledge with this quiz. Medscape , September 03, 2024
• Breast Cancer e-Tumor Boards: Case 5: Metastatic High-Grade Neuroendocrine Carcinoma   This case focuses on an 85-year-old woman with metastatic high-grade neuroendocrine carcinoma that was thought to be of GI origin. Her history goes back to 2016 when she was initially diagnosed with breast cancer. The team reviews her case through the lens of genomics and discusses treatment options. Medscape , August 30, 2024
• A Smoker With Chest Pain After Eating A 53-year-old man with substernal chest pain and a nagging, dry cough has been using marijuana edibles to increase his low appetite. What's causing his underlying symptoms? Medscape , August 28, 2024
• Skill Checkup: A Man With Chest Pain and Dyspnea A man presents with episodes of acute onset of chest pain (that radiates down his left arm) and dyspnea and diaphoresis after a long nap. How would you manage this patient? Medscape , August 28, 2024
• Fast Five Quiz: Don't Give Up on Smoking Cessation Are you aware of the latest approaches to smoking cessation and how and when to recommend different smoking cessation aids to patients? Take this short quiz to find out. Medscape , August 27, 2024
• Abdominal Abscess in a 70-Year-Old The abscess was surgically drained and custard-like pus was encountered. Medscape , August 26, 2024
• Patient Simulation: A 22-Year-Old Woman With Worsening Atopic Dermatitis A 22-year-old university student has worsening atopic dermatitis despite ongoing treatment. How would you manage, and what treatment options would you consider for this patient's disease progression? Medscape , August 22, 2024
• Fast Five Quiz: Can You Spot Depression? Are you prepared to diagnose patients who present with signs of depression? Take this short quiz and find out. Medscape , August 21, 2024
• Rapid Review Quiz: Recognizing Malingering How familiar are you with malingering and how it may affect your patients? Test yourself with this short quiz. Medscape , August 21, 2024
• Persistent, Painful Lower-Extremity Nodules The pain wakes this woman up at night, and her mobility is limited. Medscape , August 21, 2024
• Rapid Review News Quiz: August 2024 Take this quick quiz on significant medical developments over the past 30 days. Medscape , August 21, 2024

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Faculty Case Studies

The purpose of this project was to develop a repository of NextGen NCLEX case studies that can be accessed by all faculty members in Maryland.

Detailed information about how faculty members can use these case students is in this PowerPoint document .

The case studies are in a Word document and can be modified by faculty members as they determine. 

NOTE: The answers to the questions found in the NextGen NCLEX Test Bank  are only available in these faculty case studies. When students take the Test Bank questions, they will not get feedback on correct answers. Students and faculty should review test results and correct answers together.

The case studies are contained in 4 categories: Family (13 case studies), Fundamentals and Mental Health (14 case studies) and Medical Surgical (20 case studies). In addition the folder labeled minireviews contains PowerPoint sessions with combinations of case studies and standalone items. 

Family  ▾

• Attention Deficit Hyperactivity Disorder - Pediatric
• Ectopic Pregnancy
• Febrile Seizures
• Gestational Diabetes
• Intimate Partner Violence
• Neonatal Jaundice
• Neonatal Respiratory Distress Syndrome
• Pediatric Hypoglycemia
• Pediatric Anaphylaxis
• Pediatric Diarrhea and Dehydration
• Pediatric Intussusception
• Pediatric Sickle Cell
• Postpartum Hemmorhage
• Poststreptococcal Glomerulonephritis Pediatric
• Preeclampsia

Fundamentals and Mental Health  ▾

• Abdominal Surgery Postoperative Care
• Anorexia with Dehydration
• Catheter Related Urinary Tract Infection
• Deep Vein Thrombosis
• Dehydration Alzheimers
• Electroconvulsive Therapy
• Home Safety I
• Home Safety II
• Neuroleptic Maligant Syndrome
• Opioid Overdose
• Post Operative Atelectasis
• Post-traumatic Stress
• Pressure Injury
• Substance Use Withdrawal and Pain Control
• Suicide Prevention
• Tardive Dyskinesia
• Transfusion Reaction
• Urinary Tract infection

Medical Surgical  ▾

• Acute Asthma
• Acute Respiratory Distress
• Breast Cancer
• Chest Pain (MI)
• Compartment Syndrome
• Deep Vein Thrombosis II
• End Stage Renal Disease and Dialysis
• Gastroesphageal Reflux
• Heart Failure
• HIV with Opportunistic Infection
• Ketoacidosis
• Liver Failure
• Prostate Cancer
• Spine Surgery
• Tension Pneumothorax
• Thyroid Storm
• Tuberculosis

Community Based  ▾

Mini Review  ▾

• Comprehensive Review
• Fundamentals
• Maternal Newborn Review
• Medical Surgical Nursing
• Mental Health Review
• Mini Review Faculty Summaries
• Mini Review Training for Website
• Mini Reviews Student Worksheets
• Pediatric Review

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Medical Coding Tutorial

• What is Medical Coding?
• What are Medical Coding Systems?
• Importance of Medical Coding
• What are Medical Coding Guidelines?
• What is Medical Decision-Making Level?
• What is ICD-10 coding?
• What is CPT Coding?
• What is HCPCS coding?
• What are HIPAA Regulations?
• What is Protected Health Information?
• Anatomy and Physiology Fundamentals
• Human Anatomy: An Overview of Major Body Systems, Organs, and Tissues
• Physiology Basics: Understanding Body Functions for Accurate Medical Coding
• ICD-10-CM Coding Overview
• Code Structure of ICD-10-CM Coding
• Coding Conventions of Medical Coding
• Coding Guidelines for ICD-10-CM
• How to navigate the Code Sets?

Medical Coding Case Studies: Practice Coding Real-World Scenarios

• Tough Medical Coding Case Studies
• Current Procedural Terminology Coding System
• CPT Coding Categories
• What is Chief Complaint?
• What is History of the Present Illness?
• What are Surgical Modifiers?
• What are Bundled Procedures?
• Evaluation and Management (E/M) Codes in CPT coding system
• CPT Coding: Case Studies
• EM Coding: Case Studies
• Inpatient E/M coding Case Studies
• Outpatient E/M Coding Case Studies
• Difference between inpatient and outpatient E/M coding
• What is the HCPCS Coding?
• What is DMPEOS Coding?
• HCPCS Overview
• What is Medical Coding Compliance?
• Ethical Considerations in Medical Coding
• Medical Coding Compliance and Fraud
• Health Insurance Portability and Accountability Act (HIPAA)
• Medical Coding Auditing and Documentation
• What Medical Billing?
• Revenue Cycle Management in Medical Billing
• Medical Coding and Reimbursement Relationship
• Medical Coding Claim Submission
• What are Medical Terminologies?
• Medical Language Basics for Improved Coding Accuracy
• Medical Terminologies: Prefixes, Suffixes, and Root Words

Module 1: Introduction to Medical Coding

Module 2: anatomy and physiology fundamentals, module 3: icd-10-cm coding, module 4: cpt coding, module 5: hcpcs level ii coding, module 6: medical coding compliance and ethics, module 7: medical billing and reimbursement, module 8: medical terminology, module 10: medical coding interview questions & answers, join our community on telegram, join the biggest community of pharma students and professionals..

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Below are practice medical coding study cases meant to provide you with some real-world case studies. Keep in mind that medical coding requires knowledge of the current coding systems, such as ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) for diagnosis coding and CPT (Current Procedural Terminology) for procedure coding. 

Here are a few case studies for you to practice medical coding:

Case Study 1: Diagnosis Coding

Patient: John Smith

Age: 45 years

Chief Complaint: Severe abdominal pain and vomiting

Medical History: Hypertension, Diabetes Type 2

Assessment and Diagnosis: Acute pancreatitis due to gallstones

Case Study 2: Procedure Coding

Patient: Jane Doe

Age: 62 years

Procedure: Total knee replacement surgery (right knee)

Medical History: Osteoarthritis

Case Study 3: Inpatient Coding

Patient: Robert Johnson

Age: 70 years

Admission Diagnosis: Myocardial Infarction (Heart Attack)

Procedures: Percutaneous Coronary Intervention (PCI) with stent placement

Medical History: Hypertension, Hyperlipidemia, Diabetes Type 2

Case Study 4: Ambulatory Surgery Coding

Patient: Emily Adams

Age: 32 years

Procedure: Laparoscopic cholecystectomy (gallbladder removal)

Chief Complaint: Recurrent upper abdominal pain

Medical History: No significant medical history

Please code each case study using the appropriate coding system (ICD-10-CM for diagnoses and CPT for procedures). If you are unsure about any specific codes or guidelines, feel free to ask for clarification.

Remember, medical coding accuracy is crucial for proper billing, reimbursement, and healthcare data analysis. Double-check your codes and make sure they accurately reflect the information provided in each case study.

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CASE STUDIES

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Filter by: Clear Filters

This page offers a collection of interesting cases from the Penn Department of Pathology and Laboratory Medicine that are available to download as PDFs. To view specific case studies by organ system or subspecialty, use the filter checkboxes in the left sidebar.

56-year-old woman with 3.5 cm large right nasal mass, resected after 2 nondiagnostic biopsies

33-year-old man with complex ethmoid sinus mass and imaging concerning for a sinonasal malignancy, 34-year-old man with aml with sudden onset of headache and fever, 36-year-old woman presenting with hemoptysis, 65-year-old man with 2.3 cm right lower thyroid nodule, 56-year-old female presenting with a 3-month history of abdominal pain, 55-year-old male presenting with back pain, 62-year-old man with a right posterior nasal mass, 65-year-old female with a mass involving the maxillary sinus, 74-year-old female with an extradural tumor compressing the right frontal lobe, 35-year-old man with chronic rhinosinusitis and nasal septal perforation, 54-year-old man with a 3.6 cm right neck mass, 21-year-old man with asthma, chronic sinusitis, polyps, headache and proptosis, 57-year-old woman with a renal mass, 63-year-old man with history of iv drug use, 72-year-old man with polypoid esophageal mass, 20-year-old woman with 3 cm mass in the tail of pancreas, 40-year-old man with increasing frequency of hypoglycemic spells, 52-year-old woman with transient symptomatic hyperthyroidism, stay connected.

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Researchers Gave LSD and Humans To Dogs — And Something Magical Happened

We’ve found our leading candidate for most interesting study of the year.

Sometimes it feels like your dog just gets you in a way nobody else does. That’s partially because of a neurological function underpinning social connection known as inter-brain activity coupling. In short, the phenomenon is like a telepathic path to friendship, where simultaneous brain activity between two individuals primes them for social engagement. Animals are social creatures and so it’s no surprise that the phenomenon of synchronized neural activity between individuals has been documented in humans , mice , bats , and monkeys , but never between two distinct species. Until now.

New research confirms what dog lovers have always known — that humans and dogs connect on the neural level. While there’s nothing necessarily profound about this finding — not on a gut level at least — the researchers were tackling this concept for a much more heady aim.

To understand how inter-brain activity coupling may manifest differently in individuals with autism spectrum disorder (ASD), and whether there’s a way to stimulate this synchronization, the researchers looked at the interaction between dogs with common genetic markers for ASD — and then gave the dogs LSD, and a human to interact with. All in the name of mind-bending scientific progress.

In a new paper published today in the journal Advanced Science , researchers from China and the U.K. become the first to demonstrate inter-brain activity coupling between two species. The study goes on to illustrate not only how a mutation associated with ASD is linked to much lower coupling, but how a dose of LSD could help two brains intertwine.

Using 10 beagles, the team performed 5 days of social experiments on pairs of unfamiliar dogs and humans. Participants wore electroencephalogram (EEG) caps to measure brain activity during 3 social interactions: when the human and dog were in different rooms, in the same room but not interacting, and in the same room while interacting, each for 5 minutes at a time. Inter-brain synchronization, the authors found, increased in the frontal and parietal lobes of the brain, both of which deal with attention, during the most intense social interactions like petting and looking at each other. This correlation continued to strengthen over the 5 days.

Next, the authors repeated the experiment using 13 dogs bred with Shank3 mutations, which are the most common genetic risk factors for ASD. The Shank3 mutants showed a loss of inter-brain activity coupling during interactions with humans, indicating this connection’s absence. However, 24 hours after administering a dose of LSD (7.5 μg per kg^-1 bodyweight), the authors observed much higher inter-brain correlation in the dogs’ frontal and parietal brain regions, outperforming dogs who had received a saline solution.

That’s a lot to unpack. Demonstrating a few firsts, this study crucially reveals how LSD can potentially promote inter-brain activity coupling in individuals with ASD. The next challenge is to elucidate the biomechanisms behind why this happens. Until then, we can rest assured that when your pup gives you a deep loving look, it’s as real as it gets.

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Forensic report inconclusive on rape in rg kar case, cbi probes new leads amid evidence destruction fears | exclusive.

Reported By : Arunima

Edited By: Oindrila Mukherjee

Last Updated: September 10, 2024, 13:20 IST

Kolkata, India

The CBI’s fresh leads likely point towards the destruction of evidence in the RG Kar rape-murder case. (Image: PTI/File)

Sources said the post-mortem report in the RG Kar rape-murder case is clear on sexual assault, but the forensic report is inconclusive on the findings

The post-mortem and forensic reports have emerged as the biggest challenge for the Central Bureau of Investigation (CBI) in its ongoing investigation into the rape and murder of a trainee doctor at Kolkata’s RG Kar Medical College and Hospital. Sources told CNN-News18 that while the post-mortem report is clear on sexual assault in the case, the forensic report is inconclusive on this.

Presenting its status report to the Supreme Court on Monday (September 9), the CBI also indicated that it has fresh leads in the case, which likely point towards the destruction of evidence. The woman doctor’s family has also made similar allegations.

“The CBI has fresh leads. Let them investigate it and submit a fresh status report by September 17,” Chief Justice of India (CJI) DY Chandrachud said during the hearing.

Meanwhile, the parents of the deceased doctor have alleged that the Kolkata Police offered them money in an attempt to suppress the case and “were in a hurry to cremate the body”. However, the allegations were refuted by the police, which said they were prompt in arresting the accused in the case and handing over the case to the CBI.

Here is all that the CBI may consider as it looks into new evidence:

Post-mortem, forensic reports pose more questions

According to sources, the post-mortem report is clear on sexual assault but the forensic report did not give conclusive findings.

The post-mortem report states that the woman doctor died of the effects of manual strangulation associated with smothering, and there is medical evidence of forceful penetration/insertion, sources said. There is also a third document that concludes that the DNA samples of Sanjay Roy, who was arrested in the case, match those recovered from the victim’s body, the sources added.

Solicitor-General Tushar Mehta flagged the discrepancy in the forensic report before the Supreme Court, raising questions about the collection of this crucial evidence. “This is serious. The person enters, the body parts were not covered, she is nude, there are injury marks and yet see the result of forensic lab. Who collected the sample then becomes relevant,” he said.

The forensic tests in question were done at a laboratory in West Bengal, and the CBI has now decided to send this report to the All India Institute Of Medical Sciences Delhi (AIIMS) and all central forensic labs for further probe. The manner in which the post-mortem was conducted is also being probed by the central agency.

The top court also questioned the missing challan , which is needed to proceed with an autopsy. However, senior advocate Kapil Sibal, representing the West Bengal government, failed to produce the challan, leading to strong observations from the CJI-led bench.

Asked about the challan , Kolkata Police officials told CNN-News18 that “nothing was missing”. The document is crucial since it includes details of the clothes that the victim was wearing when the body was brought in. Sources said the post-mortem report mentioned that the doctor was wearing a pink top, but her innerwear was missing.

Sources further said it is likely that the laptop and mobile phone of the victim were tampered with, which is also being probed. The two devices, along with a notepad, were found near her body while some sheets were missing from the notepad and there were no fingerprints on the gadgets, they said.

Police response to the woman doctor’s death

The parents of the woman doctor alleged that the Kolkata Police, specifically the deputy commissioner of police (north), offered them money to “hush up the case”. The CBI is probing the motive behind such an offer.

It is also looking afresh at one Avik De, who was present at the crime scene, as per pictures that went viral. The police identified him as a forensic expert, but the Indian Medical Association (IMA) has called him out as one of the doctors close to former RG Kar principal, Sandip Ghosh. Hence, the presence of an alleged Ghosh aide has led to questions.

Role of former RG Kar Hospital principal Sandip Ghosh

The CBI is also examining if Dr Sandip Ghosh revealed all the facts while narrating the sequence of events on August 9, the day the victim’s body was found inside the seminar hall at RG Kar Hospital. He had claimed that he found out about the murder only around 10.20 am, but sources said in his driver’s statement to the CBI, it is mentioned that he got a call to urgently reach the Ghosh residence at 6 am. It is not yet clear what this emergency was even after the agency subjected the ex-principal to more than 15 days of questioning and made him undergo two lie-detection tests.

• Central Bureau of Investigation
• RG Kar Hospital

No difference in 6-month functional outcome between early and late decompressive craniectomies following acute ischaemic stroke in a national neurosurgical centre: a single-centre retrospective case-cohort study

• Original Article
• Published: 10 September 2024

Cite this article

• Adina S. Nesa 1 ,
• Conor Gormley 1 ,
• Christopher Read 1 ,
• Sarah Power 2 ,
• Donncha O’Brien 3 ,
• Darragh Herlihy 2 ,
• Karl Boyle 4 &
• Caroline M. Larkin   ORCID: orcid.org/0000-0001-5373-3978 1  

Decompressive craniectomies (DCs) are recommended for the treatment of raised intracranial pressure after acute ischaemic stroke. Some studies have demonstrated improved outcomes with early decompressive craniectomy (< 48 h from onset) in patients with malignant cerebral oedema following middle cerebral artery infarction. Limited data is available on suboccipital decompressive craniectomy after cerebellar infarction.

Our primary objective was to determine whether the timing of DCs influenced functional outcomes at 6 months. Our secondary objectives were to analyse whether age, gender, the territory of stroke, or preceding thrombectomy impacts functional outcome post-DC.

We conducted a retrospective study of patients admitted between January 2014 and December 2020 who had DCs post-acute ischaemic stroke. Data was collected from ICU electronic records, individual patient charts, and the stroke database.

Twenty-six patients had early DC (19 anterior/7 posterior) and 21 patients had late DC (17 anterior/4 posterior). There was no difference in the modified Rankin Scale (mRS) score of the two groups at 90 ( p  = 0.318) and 180 ( p  = 0.333) days post early vs late DC. Overall outcomes were poor, with 5 out of 46 patients (10.9%) having a mRS score ≤ 3 at 6 months. There was no difference in mRS scores between the patients who had hemicraniectomies for anterior circulation stroke ( n  = 35) and suboccipital DC for posterior circulation stroke ( n  = 11) ( p  = 0.594).

In this single-centre retrospective study, we found no significant difference in functional outcomes between patients who had early or late DC after ischaemic stroke.

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Data availability

The data that support the findings of this study are available on request from the corresponding author, CL. The data are not publicly available because they contain information that could compromise the privacy of research participants.

Powers WJ, Rabinstein AA, Ackerson T et al (2018) 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 49(3):e46–e110. https://doi.org/10.1161/str.0000000000000158

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Vahedi K, Hofmeijer J, Juettler E et al (2007) Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 6(3):215–222. https://doi.org/10.1016/s1474-4422(07)70036-4

Nouh A, Remke J, Ruland S (2014) Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management. Front Neurol 5:30. https://doi.org/10.3389/fneur.2014.00030

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Ayling OGS, Alotaibi NM, Wang JZ et al (2018) Suboccipital decompressive craniectomy for cerebellar infarction: a systematic review and meta-analysis. World Neurosurg 110:450-459.e5. https://doi.org/10.1016/j.wneu.2017.10.144

Jüttler E, Unterberg A, Woitzik J et al (2014) Hemicraniectomy in older patients with extensive middle-cerebral-artery stroke. N Engl J Med 370(12):1091–1100. https://doi.org/10.1056/NEJMoa1311367

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Department of Anaesthetics and Intensive Care Medicine, Beaumont Hospital, Dublin, Ireland

Adina S. Nesa, Conor Gormley, Christopher Read & Caroline M. Larkin

Department of Neuroradiology, Beaumont Hospital, Dublin, Ireland

Sarah Power & Darragh Herlihy

Department of Neurosurgery, Beaumont Hospital, Dublin, Ireland

Donncha O’Brien

Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin, Ireland

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Adina S. Nesa, Caroline M. Larkin, Karl Boyle, Donncha O’Brien, and Sarah Power contributed to the study conception and design. Data collection was performed by Adina S. Nesa, Connor Gormley, Darragh Herlihy, and Christopher Read. Manuscript preparation was performed by Adina S. Nesa, Caroline M. Larkin, Sarah Power, Donncha O’Brien, and Karl Boyle. Data analysis was performed by Adina S. Nesa, Caroline M. Larkin, and Karl Boyle. The first draft of the manuscript was written by Adina S. Nesa, and all authors commented on previous versions of the manuscript. Authorship requirements have been met, and all authors have read and approved the final manuscript.

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Correspondence to Caroline M. Larkin .

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This research study was conducted retrospectively from data obtained for clinical purposes. The clinical audit division of Beaumont Hospital approved this study as a retrospective chart review (CA2021/012) and was exempted from informed consent. This manuscript complies with instructions to the authors.

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Nesa, A.S., Gormley, C., Read, C. et al. No difference in 6-month functional outcome between early and late decompressive craniectomies following acute ischaemic stroke in a national neurosurgical centre: a single-centre retrospective case-cohort study. Ir J Med Sci (2024). https://doi.org/10.1007/s11845-024-03801-7

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Published : 10 September 2024

DOI : https://doi.org/10.1007/s11845-024-03801-7

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