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Terms in this set (70)

CASE 1
Reason for consult: Acute renal failure (Indication for the visit.)
HPI: The patient was followed in the past by my associate for CKD, with baseline creatinine of 1.8 two weeks ago. Found to have severe ARF this morning associated with acidosis and moderate hyperkalemia after presenting to the ER with complaint of dehydration. (These conditions were diagnosed by another physician in the emergency room.) The patient is admitted under observation status to the hospitalist service and the renal team is called for a consult.
ROS: Cardiovascular: Negative for CP/PND. GI: Negative for nausea, positive for diarrhea. GU: Negative for obstructive symptoms or documented exposure to nephrotoxins. All other systems reviewed and are negative.
PFSH: Negative family history of hereditary renal disease and negative history of tobacco or ETOH abuse.
EXAM: Constitutional: 99/52, 18, 102. NAD. Conversant. Eyes: anicteric sclera, no proptosis, PERRL. ENMT: Normal aside from somewhat dry mucus membranes. Cardiovascular: RRR, no MRGs, no edema. Respiratory: Lungs CTA, normal respiratory effort. GI: NABS, no HSM. Skin: Warm and dry, decreased turgor. Psychiatric: A&OX3 with appropriate affect.
Labs: BUN = 99, creatinine = 3.6, HCO3 = 14, K = 5.9.
IMPRESSION
1. New, acute renal failure, due to dehydration
2. Underlying stage III CKD
3. Mild hypotension
(Code the definitive diagnoses documented by the provider.)
PLAN
1. Bolus with another liter of NS wide open.
2. Then start D5W with 3 amps of HCO3 at 150 cc/hr.
3. Repeat labs in eight hours.
4. Further diagnostic testing will be ordered if there is no improvement of volume repletion.
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CASE 2
PROGRESS NOTE
Chief complaint: Multiple ulcers.
Subjective: The patient returns, accompanied by her caregiver who states that she believes the ulcers have gotten "about as good as they are going to." The edema of the leg seems to be controlled much better.
Objective: Exam reveals marked improvement of the edema (The edema is improving.) of both lower legs, the right is better than the left. All of the ulcers are now extremely superficial and seem to almost be partial thickness skin.(The ulcers are healing.) There is no cellulitis. The only uncomfortable area seems to be on the sole of the left foot where there are considerable bony abnormality and/or tophaceous deposits which have distorted the bottom of her foot dramatically. To relieve the left foot pain,(Location of the foot pain. Patient had foot pain likely due to tophaceous deposits which are an indication of gout. This is not a definitive diagnosis documented by the provider. Code the symptom.) a sole nerve block posterior to the lateral malleolus is carried out with a 50:50 mixture of 1% lidocaine with epinephrine and .5% marcaine. Following this, she gets good relief from the pain of the lateral posterior part of the foot. The legs are cleansed with Hibiclens and multi-layer compression wraps are reapplied by the PA.
Assessment: Ulcers are on the feet.(Location of the ulcers.) Edema is in the lower extremities. Foot pain is (Report the codes for the definitive diagnoses. Procedure performed for foot pain.) treated with a nerve block. Fantastic course to date, thanks to her caregiver
Plan: Continue with wound care as before. Return to the office in six to eight weeks; at which time, assuming everything is going well, we could set up an OR time for panniculectomy. She appears to understand and is willing to proceed.
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CASE 4
CHIEF COMPLAINT: Right shoulder injury.(Patient's complaint.)
MODE OF ARRIVAL: Private vehicle.
HISTORY OF PRESENT ILLNESS: The patient is a 59-year-old male who states that just prior to arrival he was going into a supermarket (Where accident occurred) when the revolving door suddenly slammed on him(How accident happened). It caught him across the right side of his chest anteriorly and posteriorly.(Location of the chest injury.) He was unable to liberate himself from the door, and an employee had to help him out. He denies any current shortness of breath, although did say he had the wind knocked out of him. He complains of pain in the anterior and posterior chest wall, posteriorly medial to the scapula. He denies any numbness, tingling or weakness in his right arm; however, he does state that it seems to be painful and difficult for him to either lift or even drop his arm. He again denies any numbness, tingling, or weakness distally. He denies any injury to his head or neck; although, he had a temporary episode of spasms on the left side of his neck. He has not taken anything for pain.
REVIEW OF SYSTEMS: Negative for fevers, chills, or unintentional weight loss. No neck pain, numbness, tingling, weakness, nausea, vomiting, shortness of breath, hemoptysis or cough.
All other systems have been reviewed and are negative except as noted.

PHYSICAL EXAMINATION:
General: The patient is awake and alert, lying comfortably in the treatment bed, he is nontoxic in appearance.
Vital Signs: Temperature= 98.3, pulse= 81, respirations= 16, blood pressure= 134/81, pulse oximetry= 95% on room air.
HEENT: The head is normocephalic and atraumatic.
Neck: Non-tender to palpation in the posterior midline. The trachea is midline. There is no subcutaneous emphysema. There is no tenderness over the paraspinous muscles.
Heart: Regular rate and rhythm without murmurs
Lungs: Clear to auscultation bilaterally without wheezes, crackles or rhonchi. The chest wall does expand
symmetrically.
Thorax/Chest Wall: Demonstrates mild tenderness anteriorly and demonstrates distinct tenderness posteriorly along the medial aspect of the scapula. No bruising or ecchymosis is noted on the skin of the chest wall. Patient keeps his right shoulder lowered. There is no deformity noted. There is no tenderness over the right clavicle. No bony deformity is noted there. There is no subcutaneous emphysema of the chest wall.
Extremities: Warm and dry without clubbing, cyanosis or edema. Grip strength is 5/5 bilaterally. Patient can flex and extend all fingers without difficulty. He can pronate and supinate at the elbow. He complains of pain in the shoulder when he flexes and extends at the elbow. Normal radial and ulnar pulses are appreciated in the bilateral upper extremities. Capillary refill is brisk. Sensation is normal in all nerve distributions in the bilateral arms.
Abdomen: Soft, non-distended. Non-tender.
Diagnostics: Two views of the chest, PA and lateral, and three views of the right shoulder were obtained. ED course: The patient received a total of 2 mg of Dilaudid for pain, 1 mg of sublingual Ativan. His arm was placed in a sling This was well tolerated and the patient was discharged home.
Medical Decision Making: It appears the patient has an anterior chest wall and a posterior chest wall contusion. The exact reasoning why he has so much difficulty moving the shoulder is unclear at this time, as he is completely neurologically intact from what I can tell. He can adduct and abduct at the shoulder, as I have seen him do it as he was moving around to be examined. X-rays demonstrate no evidence of fracture or dislocation. At this point, I am discharging the patient home, having him use ice packs, doing prescriptions for pain medications and having him return for new or worsening symptoms.
IMPRESSION:
1 Anterior and posterior chest wall contusion.
2 Right shoulder injury.
(Report codes for the definitive diagnosis.)
PLAN: Discharge home. Return for new or worsening symptoms. Sling for comfort.
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CASE 7
PREOPERATIVE DIAGNOSIS:
1. 2 cm transverse laceration of right forehead.
2. 3 cm stellate laceration of right upper eyelid.
3. 3 cm trap door laceration of right lower eyelid.
OPERATIVE DIAGNOSIS:
OPERATION PERFORMED: Multiple-layer closure of above lacerations totaling 8 cm.
Anesthesia: Local.
PREOPERATIVE NOTE: This patient is a 64-year-old white female. She has a very difficult time ambulating, doing so with a walker and intermittently sitting. This evening, unfortunately, she fell from her motorized wheelchair that was moving and struck the right side of her forehead. She was brought to the emergency department where she was thoroughly evaluated by Dr. Tim and is in the process of getting C-spine films and is accordingly in a cervical spine support. I was called to evaluate and treat these lacerations due to their extensive and complex nature. The lacerations are as described above. Forehead laceration is linear, deep, but otherwise uneventful. The upper right eyelid laceration is approximately 3 cm in length and the medial aspect of it is somewhat dusky because it is very thin and devoid of vasculature. The lower eyelid laceration is trap door and somewhat deep. It also becomes very thin at the medial aspect; however, there appears to be no duskiness. It seems to be well vascularized. In any event, we chose to immediately repair these with local anesthesia.
DETAILS OF OPERATIVE PROCEDURE: Approximately a total of 6 ml of 2% lidocaine with 1:100,000 epinephrine was infiltrated into the three wounds. They were then thoroughly cleansed with soap, and closure was begun on the upper eyelid. We used 6-0 vicryl subcutaneous sutures to attack the flap back into position, and once this was accomplished, we used individual 6-0 Prolene sutures on the skin to complete the closure. Attention was then turned to the right lower eyelid laceration where essentially an identical procedure was done. The wounds were somewhat similar in that they were flaps pedicled to the lateral towards the medial. Again, we used 6-0 vicryl subcutaneous and 6-0 Prolene individual skin sutures. Finally, attention was turned to the forehead laceration which was similarly closed with these same sutures, 6-0 vicryl subcutaneous and 6-0 Prolene on the skin. The wounds were then dressed with Bacitracin ophthalmic. Patient was instructed to keep them moist at all times and to not let crust form. She was also instructed in the appropriate analgesics to be taken orally and given my office number for a follow-up appointment. At the end of the procedure, she was then sent back to x-ray for CT scan of her C-spine.
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CASE 8
PREOPERATIVE DIAGNOSIS:
Right forearm radial shaft fracture with possible mild distal radioulnar joint subluxation.
POSTOPERATIVE DIAGNOSIS:
Right forearm radial shaft comminuted fracture with possible mild distal radioulnar joint subluxation.
ANESTHESIA: Axillary block with general anesthesia.
OPERATION: Right radius fracture open reduction and internal fixation with closed reduction distal radioulnar joint
INDICATIONS: This is a 22-year-old male, who sustained a right forearm fracture injury as indicated above and in the medical records and office notes.
DESCRIPTION OF PROCEDURE: The patient was placed under axillary block in the holding area, followed by general in the operating room. Patient identification, correct procedure, and site were confirmed. Antibiotics were provided in an appropriate fashion preoperatively.
A dorsal/posterior approach to the fracture was performed with a standard recommended incision, location and technique. The interval between the extensor carpi radialis brevis and extensor digitorum communis was developed. The extensor pollicis brevis and the abductor pollicis were gently retracted one way or the other to expose the fracture site, and the fracture was just beneath this area. The radial sensory nerve was identified and protected throughout the procedure. The fracture was exposed with minimal soft tissue stripping. The bone holding forceps were placed on either side of the fracture, the overriding fracture was manipulated with gentle traction, and the fracture reduced. This effectively reduced the distal radioulnar joint.
A small fragment, Synthes DCP locking plate was utilized to fix the fracture. Eight holes were utilized. Due to the nature of the fracture and the anatomy, there were three screws distal, four screws proximal, and the last hole was at the area of the fracture. Initially to achieve satisfactory bone to plate contact, three lag screws were required and these were placed initially. This was followed by placement of the remaining screws that were utilized proximal and distal to the fracture site to be locking screws. Intraoperative X-rays utilizing the C-arm were performed throughout the procedure to guide fracture reduction and hardware replacement. Final X-rays demonstrated excellent alignment of the fracture in the distal radioulnar joint. Excellent coaptation of the bony surfaces was obtained.
Final irrigation of the wound was performed. The wound was closed in layers in a standard fashion. Splints were applied. Total tourniquet time was approximately 60 minutes. The patient tolerated the procedure well and went to the recovery room in satisfactory condition. Sponge and needle count is correct x2. Estimated blood loss is minimal.
What diagnosis code(s) are reported?

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CASE 10
This 67-year-old Medicare patient is seen for a screening Pap and pelvic examination at our office today. She is an established patient and is complaining of abnormal vaginal discharge on and off for approximately three weeks. She denied any trauma. Patient is not sexually active and her LMP was ten years ago. She denies any chest pain, shortness of breath or urinary problems. Patient had Pap and pelvic exam one year ago and is requesting a Pap and pelvic exam today. Patient was presented with an ABN which was signed.
Past Medical History: Two vaginal deliveries, one in 1965 and another in 1967. Allergies, unknown. Medications include Micardis 80 mg for hypertension. She does not smoke or drink. She is married and lives with her husband.
Examination: Vital signs: BP= 125/70. Pulse= 85, respirations= 20. Height= 5' 5". Weight= 135 lbs. Well-developed, well-nourished female in no acute distress.
HEENT: Pupils equal, round and reactive to light and accommodation. Extraocular muscles are intact.
Neck: Thyroid not palpable. No jugular distention. Carotid pulses are present bilaterally.
Breasts: Manual breast exam reveals no masses, tenderness or nipple discharge. The breasts are asymmetrical with no nipple discharge.
Abdomen: No masses or tenderness noted. No hernias appreciated. No enlargement of the liver or spleen.
Pelvic: Vaginal examination reveals no lesions or masses. Discharge is noted and a sample was collected for testing and sent to an outside laboratory for testing. No bleeding noted. Examination of the external genitalia reveals normal pubic hair distribution. The vulva appears to be within normal limits. There are no lesions noted. A speculum is inserted. There is no evidence of prolapse. The cervix appears normal. A cervical smear is obtained and will be sent to pathology. The speculum is removed and a manual pelvic examination is performed. It appears that the uterus is smooth and no masses can be felt. Rectal examination is within normal limits. Screening occult blood is negative. Uterus is not enlarged. Urinary: Urethral meatus is normal. No masses noted for urethra or bladder.
Assessment and Plan: Routine Pap and pelvic; vaginal discharge. Patient had Pap and pelvic examination one year ago. Patient was sent to our in-house lab for blood draw today, and she is to follow-up in one week for lab results.
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C (Rationale: Burns are classified as burns or corrosions in ICD-10-CM. In this scenario, there is no specification as to what caused the burns, but they are stated as burns. ICD-10-CM guideline I.C.19.d.1 indicates to sequence first the code that reflects the highest degree of burn when more than one is present. In this case, the third degree burn on the right hand is listed first. In the ICD-10-CM Alphabetic Index, look for Burn/hand(s)/right/third degree directing you to T23.301-. In the Tabular List, a 7th character A is reported for the initial encounter (active treatment). ICD-10-CM guideline I.C.19.d.2 indicates to code burns of the same site, but of different degrees to the subcategory identifying the highest degree recorded. Therefore, report second degree burns to the left calf. Look in the Alphabetic Index for Burn/calf/left/second degree T24.232. In the Tabular List a 7th character A is reported for the initial encounter. ICD-10-CM guideline I.C.19.d.6 indicates a code from category T31 is reported when there is mention of a third-degree burn involving 20% or more of the body surface. This does not apply in this case, so a code from T31 is not required (unless reporting for a burn unit or other facility requiring the additional data). The codes in the burn section have a note to use additional external cause codes to identify the source, place and intent of the burn. This information is not known in this case so it cannot be reported. Verify code selection in the Tabular List.)