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Terms in this set (1025)

CASE INSTRUCTIONS:

To view this health record:

Click on the tabs above.
Scroll to the bottom of each document.
For your referance, the Coding Guidelines tab includes information from your codebooks.
To answer the questions in this case:

Enter the appropriate codes in the boxes on the right.
Enter a DX code in every box.
Any necessary decimal point must be present and correctly placed.
Do not include spaces with your answer.
----------
CODING GUIDELINES

Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case.
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AMBULATORY RECORD

PREOPERATIVE DIAGNOSIS: Reflex sympathetic dystrophy, left knee

POSTOPERATIVE DIAGNOSIS: Reflex sympathetic dystrophy, left knee

OPERATION: Left lumbar sympathetic block with C-arm

ANESTHESIA: Local

INDICATIONS:

This 43-year-old female has a 7-month history of left knee pain. She says that even a light touch appears to be exquisitely painful. She has had surgery to clear scar tissue.

PROCEDURE DESCRIPTION:

The patient was placed on the x-ray lucent gurney in the right lateral decubitus position. The back was prepped with Betadine, and the midline spinous processes were marked. A line was drawn 6 to 7 cm lateral to that midline on the left. L2 was identified using the C-arm and lateral projections, and lidocaine was infiltrated at the skin. The 22-gauge, 6-inch Chiba needle was advanced down to and off the body of L2, and loss of resistance was obtained with a glass syringe. Renografin-60 was injected and showed a good distribution. So 15 cc of bupivacaine 0.5% without epinephrine was injected, plus Depo-Medrol 40 mg. The needle was withdrawn.

Then lidocaine was infiltrated on the 6- to 7-cm line at L4. I advanced the 22-gauge, 6-inch needle off the body of L4, but the Renografin-60 distribution appeared not to be adequate. Another wheal was raised at the 13 level, and the needle was advanced down to and off the body of L3. A loss of resistance was obtained with a glass syringe, followed by Renografin-60. This time, the distribution was excellent, and bupivacaine 0.5% without epinephrine =15 cc was injected. She was left on her side for 25 minutes. After 10 minutes, she had a noticeably warmer left foot and ankle. The skin coloration of the left leg was normal.
---------
Enter one diagnosis code and two procedure codes.

PDX

PP1

PR2
EMERGENCY DEPARTMENT RECORD

DATE OF ADMISSION: 8/19 DATE OF DISCHARGE: 8/19

HISTORY (Problem Focused):

ADMISSION HISTORY: This is a 13-year-old African-American male. He became short of breath, used his inhaler as described but continued to have wheezing and shortness of breath.

ALLERGIES: None

CHRONIC MEDICATIONS: Albuterol inhaler

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient's father smokes one pack of cigarettes per day, but he does not smoke in the house.

REVIEW OF SYSTEMS: His integumentary, musculoskeletal, cardiovascular, genitourinary, and gastrointestinal systems are negative.

PHYSICAL EXAMINATION (Extended Problem Focused):

GENERAL APPEARANCE: This is an alert, cooperative young male in acute distress.

HEENT: PERRLA, extraocular movements are full

NECK: Supple

CHEST: Lungs reveal wheezes and rales. Heart has normal sinus rhythm.

ABDOMEN: Soft and nontender, no organomegaly

EXTREMITIES: Examination is normal.

LABORATORY DATA: Urinalysis is normal, EKG normal, chest x-ray is normal. CBC and diff show no abnormalities.

IMPRESSION: Acute asthma with exacerbation

PLAN: Administer epinephrine and intravenous theophylline

TREATMENT: Following administration of epinephrine and theophylline, the patient's asthma abated. One venipuncture set and one IV set were used to administer the medication over 30 minutes.

DISCHARGE DIAGNOSIS: Asthma with exacerbation

DISCHARGE INSTRUCTIONS: The patient was instructed to take his prescribed medications as directed by his primary care physician and to return to the ER if he had any further asthma.
------------
Enter one diagnosis code and two procedure codes.

PDX

PP1

PR2
INPATIENT RECORD

DISCHARGE SUMMARY

DATE OF ADMISSION: 2/3 DATE OF DISCHARGE: 2/5

DISCHARGE DIAGNOSIS: Full-term pregnancy—delivered male infant

Patient started labor spontaneously three days before her due date. She was brought to the hospital by automobile. Labor progressed for a while but then contractions became fewer and she delivered soon after. A midline episiotomy was done. Membranes and placenta were complete. There was some bleeding but not excessive. Patient made an uneventful recovery.
--------
H&P
ADMITTED: 2/3

REASON FOR ADMISSION: Full-term pregnancy

PAST MEDICAL HISTORY: Previous deliveries normal and mitral valve prolapse

ALLERGIES: None known

CHRONIC MEDICATIONS: None

FAMILY HISTORY: Heart disease—father

SOCIAL HISTORY: The patient is married and has one other child living with her.

REVIEW OF SYSTEMS:

SKIN: Normal

HEAD-SCALP: Normal

EYES: Normal

ENT: Normal

NECK: Normal

BREASTS: Normal

THORAX: Normal

LUNGS: Normal

HEART: Slight midsystolic click with late systolic murmur II/VI

ABDOMEN: Normal

IMPRESSION: Good health with term pregnancy. History of mitral valve prolapse—asymptomatic.

------------
PROGRESS NOTES

DATE NOTE
2/3 Admit to Labor and Delivery. MVP stable. Patient progressing well.
Delivered at 1:15 p.m. one full-term male infant.
2/4 Patient doing well. Mitral valve prolapse stable. The perineum is clean and dry, incision intact.
2/5 Will discharge to home
----------
PHYSICIANS ORDERS

DATE ORDER
2/3 Admit to Labor and Delivery
1,000 cc 5% D/LR
May ambulate
Type and screen
CBC
May have ice chips
2/5 Discharge patient to home

-----------------
DELIVERY RECORD

DATE: 2/3

The patient was 3 cm dilated when admitted. The duration of the first stage of labor was 6 hours, second stage was 14 minutes, third stage was 5 minutes. She was given local anesthesia. An episiotomy was performed with repair. There were no lacerations. The cord was wrapped once around the baby's neck, but did not cause compression. The mother and liveborn baby were discharged from the delivery room in good condition.
-----------
LAB REPORT

HEMATOLOGY

DATE: 2/3

Specimen Results Normal Values
WBC

5.2

4.3-11.0

RBC

4.9

4.5-5.9

HGB

13.8

13.5-17.5

HCT

45

41-52

MCV

93

80-100

MCHC

41

31-57

PLT

255

150-450
----------
Enter four diagnosis codes and one procedure code.

PDX

DX2

DX3

DX4

PP1
INPATIENT

DISCHARGE SUMMARY

DATE OF ADMISSION: 9/8
DATE OF DISCHARGE: 9/10

DISCHARGE DIAGNOSIS:

Acute pyelonephritis
Septicemia, resistant to ampicillin and penicillin
ADMISSION HISTORY: This 21-year-old female was admitted to the hospital with discomfort in the right side. Other than this she has been healthy. On the day of admission she developed severe discomfort in the lower back. She was having fever and chills for which she took an aspirin and then she came to the emergency department.

COURSE IN HOSPITAL: The patient was treated with intravenous antibiotics in the form of gentamicin and cefoxitin. She continued to improve on this regimen and became afebrile after about three days of treatment. Her physical examination remained essentially unchanged; however, there was marked improvement in the patient's general condition. The patient also had an onset of herpes simplex infection on her upper lip, for which she was given Zovirax ointment.

INSTRUCTIONS ON DISCHARGE: The patient was discharged home on ciprofloxacin 500 mg p.o. b.i.d. × 12 days. A repeat blood culture done just prior to discharge showed no growth at the end of 7 days. She is to be followed up in my office in about a week after discharge to have a repeat urine culture done. The patient was also given a prescription for Zyban to assist smoking cessation.
------------
H&P

ADMITTED: 9/8

REASON FOR ADMISSION: This was the first hospital admission for this 21-year-old white female, who experienced difficulty about 3 days prior to admission. This was in the form of discomfort in the right side of the lower back and also some dysuria. On the evening of admission, she started experiencing some fever and chills and took some aspirin. This did not help her and she came to the emergency department.

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY: Remarkable only for "walking pneumonia" treated with erythromycin 3 months ago. She also suffered contusion of her right kidney after a fall from a horse about 4 years prior to admission.

ALLERGIES: None known

CHRONIC MEDICATIONS: None

FAMILY HISTORY: Remarkable for multiple members of the family having seasonal allergies

SOCIAL HISTORY: The patient lives with two friends and is employed by a saddle shop. She drinks about one drink a week and smokes a pack of cigarettes a day.

REVIEW OF SYSTEMS: The patient relates that there has been no weight gain or loss and that she was well functioning until three days ago when she developed lower back pain, primarily on the right side. She also relates that she has had dysuria for this same time period.

PHYSICAL EXAMINATION: On admission, significant for temperature of 103 degrees; pulse 120 beats per minute, regular; blood pressure 120/70; respirations 16

VITAL SIGNS: P 120/min, regular; BP 120/70; Temp 103 degrees; R 16/min, regular

GENERAL: The patient is a well-developed female of her stated age. She appears lethargic but responsive. The patient appears septic.

SKIN: Warm to touch

HEENT: Pupils equal, react briskly to light. Mucous membranes of the eyes, nose, mouth, and oropharynx are normal.

NECK: Supple, trachea is central, the carotid pulses are symmetrical. There is no goiter.

LUNGS: Clear to auscultation and percussion

BACK: Positive pain to palpation and percussion right costovertebral angle

HEART: Peripheral pulses are symmetrical. The cardiac apex is not displaced. The heart sounds are normal and there are no added sounds or murmurs.

ABDOMEN: Soft, nontender, with no masses palpable. The bowel sounds are normal.

GENITALIA: Normal female

RECTAL: Deferred

EXTREMITIES: Femoral pulses normal, no edema

NEUROLOGIC: Grossly intact

LABORATORY DATA: WBC 15.9 with differential of 57 Segs; 33 Bands; 6 Lymphs; 4 Monos. Electrolytes were normal. BUN 11. Urine culture grew out E. coli, more than 100,000 colonies per mL. Blood culture was also positive for E. coli. This was sensitive to gentamicin and cefoxitin, as well as many other antibiotics. Urinalysis on admission revealed many WBCs and marked bacteriuria. Chest x-ray was unremarkable.

IMPRESSION: Admit for clinical features of acute pyelonephritis and septicemia.

PLAN: Hydrate and start IV antibiotics.
----------
PROGRESS NOTES

DATE NOTE
9/8 Patient admitted for evaluation of flank pain and fever. She also has a lesion on her lip. This appears to be herpes simplex. Will treat infection process with antibiotics following obtaining cultures. The patient's renal function will be monitored.
9/10 The patient's fever decreasing. Patient comfortable and tolerating antibiotics. Will continue IVs. The importance of stopping cigarette use was discussed with the patient. She is willing to quit and she will be given a prescription for Zyban at discharge.
9/11 Patient is afebrile today. Will discharge when able to obtain transportation.
---------
PHYSICIANS ORDERS

DATE ORDER
9/8 Admit to floor for evaluation of febrile illness
Urinalysis
CBC and SMA 16
Urine culture and sensitivity
Blood cultures ×2
Chest x-ray
Pyelogram
D5W 125 cc/h ×3
Strict input and output
Zovirax ointment prn to lip
Gentamicin 80 mg IV q. 8 H ×3d
Cefoxitin 1 g IV q. 8 H ×3 days
9/9 D5W 100 cc/ph
9/10 Discharge patient when transportation is arranged
Ciprofloxacin 500 mg p.o. b.i.d. ×12 days
Zyban 150 mg p.o. daily ×3 days then b.i.d.
Follow up in the office in 1 week.
-------------
LAB REPORT


HEMATOLOGY

DATE: 9/8

Specimen Results Normal Values
WBC

15.9 H

4.3-11.0

RBC

5.5

4.5-5.9

HGB

14.0

13.5-17.5

HCT

45

41-52

MCV

90

80-100

MCHC

41

31-57

PLT

251

150-450

CHEMISTRY

DATE: 9/8

Specimen Results Normal Values
GLUC

100

70-110

BUN

11

8-25

CREAT

1.0

0.5-1.5

NA

143

136-146

K

4.0

3.5-5.5

CL

98

95-110

CO2

30

24-32

CA

9.0

8.4-10.5

PHOS

3.0

2.5-4.4

MG

2.0

1.6-3.0

T BILI

1.0

0.2-1.2

D BILI

0.3

0.0-0.5

PROTEIN

7.0

6.0-8.0

ALBUMIN

5.2

5.0-5.5

AST

25

0-40

ALT

40

30-65

GGT

60

15-85

LD

100-190

ALK PHOS

50-136

URIC ACID

2.2-7.7

CHOL

0-200

TRIG

10-160

URINALYSIS

DATE: 9/8

Test Result Ref Range
SP GRAVITY

1.03

1.005-1.035

PH

6

5-7

PROT

NEG

NEG

GLUC

NEG

NEG

KETONES

NEG

NEG

BILI

NEG

NEG

BLOOD

NEG

NEG

LEU EST

POS

NEG

NITRATES

POS

NEG

RED SUBS

NEG

NEG
-------------
MICROBIOLOGY

9/10 AMPICILLIN R
CEFAZOLIN S
CEFOTAXIME S
CEFTRIAXONE S
CEFUROXIME S
CEPHALOTHIN S
CIPROFLOXACIN S
ERYTHROMYCIN S
GENTAMICIN S
OXACILLIN S
PENICILLIN R
PIPERACILLIN
TETRACYCLINE
TOBRAMYCIN
TRIMETH/SULF
VANCOMYCIN
S = SUSCEPTIBLE
R = RESISTANT
I = INTERMEDIATE
M = MODERATELY SUSCEP
------------
LAB REPORT

DATE: 9/11

URINE CULTURE: No growth for 24 hours
---------------
MICROBIOLOGY

DATE TEST TYPE:

9/8 Culture and Sensitivity #1
SOURCE: Blood
SITE:
GRAM STAIN RESULTS
CULTURE RESULTS: E. coli
SUSCEPTIBILITY:

9/10 AMPICILLIN R
CEFAZOLIN S
CEFOTAXIME S
CEFTRIAXONE S
CEFUROXIME S
CEPHALOTHIN S
CIPROFLOXACIN S
ERYTHROMYCIN S
GENTAMICIN S
OXACILLIN S
PENICILLIN R
PIPERACILLIN
TETRACYCLINE
TOBRAMYCIN
TRIMETH/SULF
VANCOMYCIN
S = SUSCEPTIBLE
R = RESISTANT
I = INTERMEDIATE
M = MODERATELY SUSCEP
--------
DATE TEST TYPE:

9/8 Culture and Sensitivity #2
SOURCE: Blood
SITE:
GRAM STAIN RESULTS
CULTURE RESULTS: E. coli
SUSCEPTIBILITY:
9/10 AMPICILLIN R
CEFAZOLIN S
CEFOTAXIME S
CEFTRIAXONE S
CEFUROXIME S
CEPHALOTHIN S
CIPROFLOXACIN S
ERYTHROMYCIN S
GENTAMICIN S
OXACILLIN S
PENICILLIN R
PIPERACILLIN
TETRACYCLINE
TOBRAMYCIN
TRIMETH/SULF
VANCOMYCIN
S = SUSCEPTIBLE
R = RESISTANT
I = INTERMEDIATE
M = MODERATELY SUSCEP
---------
RAD REPORT

DATE: 9/8

CHEST X-RAY: The examination is of a recumbent AP view. Heart size is normal. The aorta is normal and lung fields are free of infiltration. There is no free air and the trachea is midline.

DIAGNOSIS: Normal chest x-ray
----------
RAD REPORT

DATE: 9/8

PYELOGRAM: The urinary architecture is normal with no hydronephrosis.

DIAGNOSIS: Normal pyelogram
------------
Enter five diagnosis codes.

PDX

DX2

DX3

DX4

DX5
Case Studies

PDX 038.42 Septicemia due to Escherichia coli
DX2 590.10 Acute pyelonephritis, without lesion of renal medullary necrosis
DX3 054.9 Herpes simplex without mention of complication
DX4 V09.0 Infection with microorganisms resistant to penicillins
DX5 305.1 Tobacco use disorder
Notes on Inpatient Practice Case—Patient 4

038.42 E. coli septicemia is documented on the culture and sensitivity as well as in the H & P. SIRS is not used here because septicemia is documented, versus sepsis. (Brown 2012, 109-112).
590.10 Acute pyelonephritis is also coded because this is where the septicemia began.

Do not code the organism (Coding Clinic 4th Quarter 1988). It is already reflected in the septicemia code (Brown 2012, 217).
054.9 Herpes simplex is documented on the 9/8 progress notes and is treated (Brown 2012, chapter 10).
305.1 Tobacco abuse is treated and documented in the progress notes, H & P and D/C summary. This code does not require a fifth digit (HHS 2011, Tabular Index; Brown 2012, chapter 12).
V09.0 The organism is specified to be resistant to in the discharge summary and therefore designate that in the coding (Brown 2012, 113).
Note: The pyelogram performed on 9/8 is not coded because it is an unspecified pyelogram (refer to the Procedures for Coding Medical Record Cases for the CCS Examination in the Introduction of this book). A pyelogram is coded only if it is code 87.74 or 87.76 (Retrogrades, urinary systems).
Points of Interest on Patient 4

This case illustrates how an infection can begin in one organ system and then become systemic. This is why the same organism is in the urinary tract and the blood. As stated earlier, code both disorders (septicemia and pyelonephritis).
The organism causing the infection is resistant to penicillin and ampicillin. Only code resistance to a drug if the resistance is documented by the practitioner in the record. Do not code from the laboratory reports alone.
(Garvin 2013, 68--75, 255.)
FACESHEET

AMBULATORY CASE

DATE OF ADMISSION: 4/5 DATE OF DISCHARGE: 4/5

SEX: Male AGE: 37 DISCHARGE DISPOSITION: Home

ADMISSION DIAGNOSIS: Left inguinal hernia

DISCHARGE DIAGNOSIS: Same

PROCEDURES: Left inguinal herniorrhaphy with excision of lipoma of spermatic cord
-------
H&P
ADMITTED: 4/5

HISTORY OF PRESENT ILLNESS: The patient has been well until several months ago when he began to have pain when lifting.

PAST MEDICAL HISTORY: The patient has no other significant medical or surgical history.

SOCIAL HISTORY: Does not use alcohol or tobacco.

ALLERGIES: No known allergies

MEDICATIONS: None

REVIEW OF SYSTEMS:

SKIN: Warm and dry, mucous membranes moist

HEENT: Essentially normal

LUNGS: Clear to percussion and auscultation

HEART: Normal, regular rhythm

ABDOMEN: Normal

GENITALIA: Palpable mass in inguinal canal

RECTAL: Normal

EXTREMITIES: No edema

NEUROLOGIC: Deep tendon reflexes normal

IMPRESSION: Left inguinal hernia

PLAN: Surgical repair of inguinal hernia
-------------
PROGRESS NOTES

DATE NOTE
4/5 Nursing:
Betadine scrub performed, patient anxious to get surgery over; preoperative medications given as ordered.
4/5 Attending MD:
Brief op note
Dx: Left inguinal hernia
Px: Left inguinal herniorrhaphy
Anes: Local plus sedation
Complications: None
4/5 Attending MD:
No bleeding; patient okay for discharge
-----------
OP REPORT

DATE: 4/5

PREOPERATIVE DIAGNOSIS: Left direct inguinal hernia

POSTOPERATIVE DIAGNOSIS: Left direct inguinal hernia

OPERATION: Left inguinal herniorrhaphy

ANESTHESIA: Local plus sedation

OPERATIVE INDICATIONS: A wide mouth direct sac was present in the lower inguinal canal. A lipoma of the cord was present, but no indirect sac.

OPERATIVE PROCEDURE: Under local anesthesia consisting of the equivalent of 19 cc of 1% Xylocaine and 8 cc of 0.5% Marcaine, the abdomen was prepared with Betadine and sterilely draped. A left inguinal incision was made and carried down through subcutaneous tissues to the aponeurosis of the external oblique, which was opened from the external ring to a point over the internal ring. Flaps were cleaned in both directions. The nerve was retracted inferiorly. The cord structures were separated from the surrounding at the level of the pubic tubercle and retracted with a Penrose drain. Cremaster over the cord was opened and a search made for an indirect sac. None was found. Lipoma of the cord was dissected free and clamped at its base and excised. The base was ligated with 00 chromic catgut. Additional cremasteric muscles were divided and ligated with 00 chromic catgut. The direct sac was further dissected down to its base and inverted as the defect was closed by approximating transversus to transversus with a running suture of 00 Vicryl. The floor of the canal was then closed by approximating the internal oblique to the shelving portion of the inguinal ligament with multiple sutures of 0 Ethibond. The external oblique aponeurosis was then reclosed with 0 Ethibond, leaving the cord and nerve in the subcutaneous position. Several sutures of 0 Ethibond were also placed above the emergence of the cord at the internal ring. Subcutaneous tissues were then approximated with 3-0 Vicryl and after irrigation skin was closed with skin clips. The patient tolerated the procedure well and was sent to the recovery room in good condition.
----------
PATH REPORT

DATE SPECIMEN SUBMITTED: 4/5

SPECIMEN: Lipoma of cord

CLINICAL DATA:

GROSS DESCRIPTION: The specimen is submitted as lipoma of cord. It consists of a single irregularly shaped fragment of fatty tissue that is 8.0 × 4.0 × 1.5 cm. It is covered with a thin membrane.

MICROSCOPIC DESCRIPTION:

DIAGNOSIS: Lipomatous tissue of left spermatic cord
----------
PHYSICIANS ORDER

DATE ORDER
4/5 Attending MD:
Admit to same-day surgery
Betadine scrub ×3 Preop
May take own meds
4/5 Anesthesia note:
Continue NPO
Demerol 50 mg IM 1½ hr Preop
Vistaril 50 mg IM 1½ hr Preop
Atropine 0.4 mg IM 1½ hr Preop
4/5 Attending MD:
Vital signs q. 15 min until stable
Regular diet
Darvocet-N-100 q. 4 hrs p.r.n. pain
Discharge to home when stable
-------------
LAB REPORT


HEMATOLOGY

DATE: 4/5

Specimen Results Normal Values
WBC

6.83

4.3-11.0

RBC

4.57

4.5-5.9

HGB

13.7

13.5-17.5

HCT

43

41-52

MCV

87.0

80-100

MCHC

35

31-57

PLT

300

150-400

AUTO DIFFERENTIAL

DATE: 4/5

Specimen Results Normal Values
NEUT

68.3

40.0-74.0

LYMPH

20

19.0-48.0

MONO

5.6

3.4-9.0

EOS

5.6

0.0-7.0

BASO

0.6

0.0-1.5

LUC

3.8

0.0-4.0

URINALYSIS

DATE: 4/5

Test Result Ref Range
SP GRAVITY

1.017

1.005-1.035

PH

6

5-7

PROT

TRACE

NEG

GLUC

NONE

NEG

KETONES

NONE

NEG

BILI

NONE

NEG

BLOOD

TRACE

NEG

NITRATES

NONE

NEG

RBCS

NONE

NEG

WBCS

NONE

NEG
-----------
RAD REPORT
-----------
Enter two diagnosis codes and two procedure codes.

PDX

DX2

PP1

PR2
AMBULATORY RECORD

To view this health record:

Click on the tabs above.
Scroll to the bottom of each document.
For your referance, the Coding Guidelines tab includes information from your codebooks.
To answer the questions in this case:

Enter the appropriate codes in the boxes on the right.
Enter a DX code in every box.
Any necessary decimal point must be present and correctly placed.
Do not include spaces with your answer.

______________
Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case.

______
DATE: 8/12/20XX

SURGERY RECORD:

PATIENT HISTORY: This patient is seen today to insert an intrathecal pump for pain management due to ductal carcinoma of the left upper breast metastatic to the spine. She previously underwent modified radical mastectomy with general anesthesia and had no adverse effects. No other surgical history is given. No known allergies, no current medications. Review of systems is normal ASA = 2.

Following preoperative evaluation and discussion with the patient, local anesthesia was used to implant an intrathecal programmable pump surgically placed and attached to a previously placed catheter. The patient tolerated the procedure well. There were no adverse effects of anesthesia.
__________
Enter three diagnosis codes and one procedure code.

PDX

DX2

DX3

PP1
EMERGENCY DEPARTMENT RECORD

DATE OF ADMISSION: 8/19 DATE OF DISCHARGE: 8/19

HISTORY (Problem Focused):

ADMISSION HISTORY: This is a 13-year-old African-American male. He became short of breath, used his inhaler as described but continued to have wheezing and shortness of breath.

ALLERGIES: None

CHRONIC MEDICATIONS: Albuterol inhaler

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient's father smokes one pack of cigarettes per day, but he does not smoke in the house.

REVIEW OF SYSTEMS: His integumentary, musculoskeletal, cardiovascular, genitourinary, and gastrointestinal systems are negative.

PHYSICAL EXAMINATION (Extended Problem Focused):

GENERAL APPEARANCE: This is an alert, cooperative young male in acute distress.

HEENT: PERRLA, extraocular movements are full

NECK: Supple

CHEST: Lungs reveal wheezes and rales. Heart has normal sinus rhythm.

ABDOMEN: Soft and nontender, no organomegaly

EXTREMITIES: Examination is normal.

LABORATORY DATA: Urinalysis is normal, EKG normal, chest x-ray is normal. CBC and diff show no abnormalities.

IMPRESSION: Acute asthma with exacerbation

PLAN: Administer epinephrine and intravenous theophylline

TREATMENT: Following administration of epinephrine and theophylline, the patient's asthma abated. One venipuncture set and one IV set were used to administer the medication over 30 minutes.

DISCHARGE DIAGNOSIS: Asthma with exacerbation

DISCHARGE INSTRUCTIONS: The patient was instructed to take his prescribed medications as directed by his primary care physician and to return to the ER if he had any further asthma.
Enter one diagnosis code and two procedure codes.

PDX

PP1

PR2
To view this health record:

Click on the tabs above.
Scroll to the bottom of each document.
For your referance, the Coding Guidelines tab includes information from your codebooks.
To answer the questions in this case:

Enter the appropriate codes in the boxes on the right.
Enter a DX code in every box.
Any necessary decimal point must be present and correctly placed.
Do not include spaces with your answer.
________________
Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case.
_________
AMBULATORY RECORD

PREOPERATIVE DIAGNOSIS: Reflex sympathetic dystrophy, left knee

POSTOPERATIVE DIAGNOSIS: Reflex sympathetic dystrophy, left knee

OPERATION: Left lumbar sympathetic block with C-arm

ANESTHESIA: Local

INDICATIONS:

This 43-year-old female has a 7-month history of left knee pain. She says that even a light touch appears to be exquisitely painful. She has had surgery to clear scar tissue.

PROCEDURE DESCRIPTION:

The patient was placed on the x-ray lucent gurney in the right lateral decubitus position. The back was prepped with Betadine, and the midline spinous processes were marked. A line was drawn 6 to 7 cm lateral to that midline on the left. L2 was identified using the C-arm and lateral projections, and lidocaine was infiltrated at the skin. The 22-gauge, 6-inch Chiba needle was advanced down to and off the body of L2, and loss of resistance was obtained with a glass syringe. Renografin-60 was injected and showed a good distribution. So 15 cc of bupivacaine 0.5% without epinephrine was injected, plus Depo-Medrol 40 mg. The needle was withdrawn.

Then lidocaine was infiltrated on the 6- to 7-cm line at L4. I advanced the 22-gauge, 6-inch needle off the body of L4, but the Renografin-60 distribution appeared not to be adequate. Another wheal was raised at the 13 level, and the needle was
advanced down to and off the body of L3. A loss of resistance was obtained with a glass syringe, followed by Renografin-60. This time, the distribution was excellent, and bupivacaine 0.5% without epinephrine =15 cc was injected. She was left on her side for 25 minutes. After 10 minutes, she had a noticeably warmer left foot and ankle. The skin coloration of the left leg was normal.
___________
Enter one diagnosis code and two procedure codes.

PDX

PP1

PR2
INPATIENT RECORD

DISCHARGE SUMMARY
DATE OF ADMISSION: 9/8 DATE OF DISCHARGE: 9/10

DISCHARGE DIAGNOSIS:

Acute pyelonephritis
Septicemia, resistant to ampicillin and penicillin
ADMISSION HISTORY: This 21-year-old female was admitted to the hospital with discomfort in the right side. Other than this she has been healthy. On the day of admission she developed severe discomfort in the lower back. She was having fever and chills for which she took an aspirin and then she came to the emergency department.

COURSE IN HOSPITAL: The patient was treated with intravenous antibiotics in the form of gentamicin and cefoxitin. She continued to improve on this regimen and became afebrile after about three days of treatment. Her physical examination remained essentially unchanged; however, there was marked improvement in the patient's general condition. The patient also had an onset of herpes simplex infection on her upper lip, for which she was given Zovirax ointment.

INSTRUCTIONS ON DISCHARGE: The patient was discharged home on ciprofloxacin 500 mg p.o. b.i.d. × 12 days. A repeat blood culture done just prior to discharge showed no growth at the end of 7 days. She is to be followed up in my office in about a week after discharge to have a repeat urine culture done. The patient was also given a prescription for Zyban to assist smoking cessation.
_____
H&P
ADMITTED: 9/8

REASON FOR ADMISSION: This was the first hospital admission for this 21-year-old white female, who experienced difficulty about 3 days prior to admission. This was in the form of discomfort in the right side of the lower back and also some dysuria. On the evening of admission, she started experiencing some fever and chills and took some aspirin. This did not help her and she came to the emergency department.

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY: Remarkable only for "walking pneumonia" treated with erythromycin 3 months ago. She also suffered contusion of her right kidney after a fall from a horse about 4 years prior to admission.

ALLERGIES: None known

CHRONIC MEDICATIONS: None

FAMILY HISTORY: Remarkable for multiple members of the family having seasonal allergies

SOCIAL HISTORY: The patient lives with two friends and is employed by a saddle shop. She drinks about one drink a week and smokes a pack of cigarettes a day.

REVIEW OF SYSTEMS: The patient relates that there has been no weight gain or loss and that she was well functioning until three days ago when she developed lower back pain, primarily on the right side. She also relates that she has had dysuria for this same time period.

PHYSICAL EXAMINATION: On admission, significant for temperature of 103 degrees; pulse 120 beats per minute, regular; blood pressure 120/70; respirations 16

VITAL SIGNS: P 120/min, regular; BP 120/70; Temp 103 degrees; R 16/min, regular

GENERAL: The patient is a well-developed female of her stated age. She appears lethargic but responsive. The patient appears septic.

SKIN: Warm to touch

HEENT: Pupils equal, react briskly to light. Mucous membranes of the eyes, nose, mouth, and oropharynx are normal.

NECK: Supple, trachea is central, the carotid pulses are symmetrical. There is no goiter.

LUNGS: Clear to auscultation and percussion

BACK: Positive pain to palpation and percussion right costovertebral angle

HEART: Peripheral pulses are symmetrical. The cardiac apex is not displaced. The heart sounds are normal and there are no added sounds or murmurs.

ABDOMEN: Soft, nontender, with no masses palpable. The bowel sounds are normal.

GENITALIA: Normal female

RECTAL: Deferred

EXTREMITIES: Femoral pulses normal, no edema

NEUROLOGIC: Grossly intact

LABORATORY DATA: WBC 15.9 with differential of 57 Segs; 33 Bands; 6 Lymphs; 4 Monos. Electrolytes were normal. BUN 11. Urine culture grew out E. coli, more than 100,000 colonies per mL. Blood culture was also positive for E. coli. This was sensitive to gentamicin and cefoxitin, as well as many other antibiotics. Urinalysis on admission revealed many WBCs and marked bacteriuria. Chest x-ray was unremarkable.

IMPRESSION: Admit for clinical features of acute pyelonephritis and septicemia.

PLAN: Hydrate and start IV antibiotics.
___________
PROGRESS NOTES

DATE NOTE
9/8 Patient admitted for evaluation of flank pain and fever. She also has a lesion on her lip. This appears to be herpes simplex. Will treat infection process with antibiotics following obtaining cultures. The patient's renal function will be monitored.
9/10 The patient's fever decreasing. Patient comfortable and tolerating antibiotics. Will continue IVs. The importance of stopping cigarette use was discussed with the patient. She is willing to quit and she will be given a prescription for Zyban at discharge.
9/11 Patient is afebrile today. Will discharge when able to obtain transportation.
______________
PHYSICIAN'S ORDER

DATE ORDER
9/8 Admit to floor for evaluation of febrile illness
Urinalysis
CBC and SMA 16
Urine culture and sensitivity
Blood cultures ×2
Chest x-ray
Pyelogram
D5W 125 cc/h ×3
Strict input and output
Zovirax ointment prn to lip
Gentamicin 80 mg IV q. 8 H ×3d
Cefoxitin 1 g IV q. 8 H ×3 days
9/9 D5W 100 cc/ph
9/10 Discharge patient when transportation is arranged
Ciprofloxacin 500 mg p.o. b.i.d. ×12 days
Zyban 150 mg p.o. daily ×3 days then b.i.d.
Follow up in the office in 1 week.
____________
LAB
HEMATOLOGY

DATE: 9/8

Specimen Results Normal Values
WBC

15.9 H

4.3-11.0

RBC

5.5

4.5-5.9

HGB

14.0

13.5-17.5

HCT

45

41-52

MCV

90

80-100

MCHC

41

31-57

PLT

251

150-450

CHEMISTRY

DATE: 9/8

Specimen Results Normal Values
GLUC

100

70-110

BUN

11

8-25

CREAT

1.0

0.5-1.5

NA

143

136-146

K

4.0

3.5-5.5

CL

98

95-110

CO2

30

24-32

CA

9.0

8.4-10.5

PHOS

3.0

2.5-4.4

MG

2.0

1.6-3.0

T BILI

1.0

0.2-1.2

D BILI

0.3

0.0-0.5

PROTEIN

7.0

6.0-8.0

ALBUMIN

5.2

5.0-5.5

AST

25

0-40

ALT

40

30-65

GGT

60

15-85

LD

100-190

ALK PHOS

50-136

URIC ACID

2.2-7.7

CHOL

0-200

TRIG

10-160

URINALYSIS

DATE: 9/8

Test Result Ref Range
SP GRAVITY

1.03

1.005-1.035

PH

6

5-7

PROT

NEG

NEG

GLUC

NEG

NEG

KETONES

NEG

NEG

BILI

NEG

NEG

BLOOD

NEG

NEG

LEU EST

POS

NEG

NITRATES

POS

NEG

RED SUBS

NEG

NEG
__________
MICROBIOLOGY

DATE TEST TYPE: Culture and Sensitivity
9/8 SOURCE: Urine
SITE:
GRAM STAIN RESULTS
CULTURE RESULTS: E. coli, 100,000/ml
SUSCEPTIBILITY:
9/10 AMPICILLIN R
CEFAZOLIN S
CEFOTAXIME S
CEFTRIAXONE S
CEFUROXIME S
CEPHALOTHIN S
CIPROFLOXACIN S
ERYTHROMYCIN S
GENTAMICIN S
OXACILLIN S
PENICILLIN R
PIPERACILLIN
TETRACYCLINE
TOBRAMYCIN
TRIMETH/SULF
VANCOMYCIN
S = SUSCEPTIBLE
R = RESISTANT
I = INTERMEDIATE
M = MODERATELY SUSCEP
____________
LAB

DATE: 9/11

URINE CULTURE: No growth for 24 hours
______________
MICROBIOLOGY

DATE TEST TYPE:
9/8 Culture and Sensitivity #1
SOURCE: Blood
SITE:
GRAM STAIN RESULTS
CULTURE RESULTS: E. coli
SUSCEPTIBILITY:
9/10 AMPICILLIN R
CEFAZOLIN S
CEFOTAXIME S
CEFTRIAXONE S
CEFUROXIME S
CEPHALOTHIN S
CIPROFLOXACIN S
ERYTHROMYCIN S
GENTAMICIN S
OXACILLIN S
PENICILLIN R
PIPERACILLIN
TETRACYCLINE
TOBRAMYCIN
TRIMETH/SULF
VANCOMYCIN
S = SUSCEPTIBLE
R = RESISTANT
I = INTERMEDIATE
M = MODERATELY SUSCEP
____________
RADIOLOGY REPORT

DATE: 9/8

CHEST X-RAY: The examination is of a recumbent AP view. Heart size is normal. The aorta is normal and lung fields are free of infiltration. There is no free air and the trachea is midline.

DIAGNOSIS: Normal chest x-ray
_________
RAD REPORT
DATE: 9/8

PYELOGRAM: The urinary architecture is normal with no hydronephrosis.

DIAGNOSIS: Normal pyelogram
nter five diagnosis codes.
____________
PDX

DX2

DX3

DX4

DX5
Case Studies
PDX 038.42 Septicemia due to Escherichia coli
DX2 590.10 Acute pyelonephritis, without lesion of renal medullary necrosis
DX3 054.9 Herpes simplex without mention of complication
DX4 V09.0 Infection with microorganisms resistant to penicillins
DX5 305.1 Tobacco use disorder


Notes on Inpatient Practice Case—Patient 4038.42 E. coli septicemia is documented on the culture and sensitivity as well as in the H & P. SIRS is not used here because septicemia is documented, versus sepsis. (Brown 2012, 109-112).
590.10 Acute pyelonephritis is also coded because this is where the septicemia began. Do not code the organism (Coding Clinic 4th Quarter 1988). It is already reflected in the septicemia code (Brown 2012, 217).
054.9 Herpes simplex is documented on the 9/8 progress notes and is treated (Brown 2012, chapter 10).
305.1 Tobacco abuse is treated and documented in the progress notes, H & P and D/C summary. This code does not require a fifth digit (HHS 2011, Tabular Index; Brown 2012, chapter 12).
V09.0 The organism is specified to be resistant to in the discharge summary and therefore designate that in the coding (Brown 2012, 113).
Note: The pyelogram performed on 9/8 is not coded because it is an unspecified pyelogram (refer to the Procedures for Coding Medical Record Cases for the CCS Examination in the Introduction of this book). A pyelogram is coded only if it is code 87.74 or 87.76 (Retrogrades, urinary systems).
____________

Points of Interest on Patient 4

This case illustrates how an infection can begin in one organ system and then become systemic. This is why the same organism is in the urinary tract and the blood. As stated earlier, code both disorders (septicemia and pyelonephritis).
The organism causing the infection is resistant to penicillin and ampicillin. Only code resistance to a drug if the resistance is documented by the practitioner in the record. Do not code from the laboratory reports alone.
(Garvin 2013, 68--75, 255.)
Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case.
________
DISCHARGE SUMMARY

DATE OF ADMISSION: 2/3
DATE OF DISCHARGE: 2/5

DISCHARGE DIAGNOSIS: Full-term pregnancy—delivered male infant

Patient started labor spontaneously three days before her due date. She was brought to the hospital by automobile. Labor progressed for a while but then contractions became fewer and she delivered soon after. A midline episiotomy was done. Membranes and placenta were complete. There was some bleeding but not excessive. Patient made an uneventful recovery.
_________
H&P

ADMITTED: 2/3

REASON FOR ADMISSION: Full-term pregnancy

PAST MEDICAL HISTORY: Previous deliveries normal and mitral valve prolapse

ALLERGIES: None known

CHRONIC MEDICATIONS: None

FAMILY HISTORY: Heart disease—father

SOCIAL HISTORY: The patient is married and has one other child living with her.

REVIEW OF SYSTEMS:

SKIN: Normal

HEAD-SCALP: Normal

EYES: Normal

ENT: Normal

NECK: Normal

BREASTS: Normal

THORAX: Normal

LUNGS: Normal

HEART: Slight midsystolic click with late systolic murmur II/VI

ABDOMEN: Normal

IMPRESSION: Good health with term pregnancy. History of mitral valve prolapse—asymptomatic.
_____________
PROGRESS NOTES

DATE NOTE
2/3 Admit to Labor and Delivery. MVP stable. Patient progressing well.
Delivered at 1:15 p.m. one full-term male infant.
2/4 Patient doing well. Mitral valve prolapse stable. The perineum is clean and dry, incision intact.
2/5 Will discharge to home
______________
PHYSICIANS ORDER

DATE ORDER
2/3 Admit to Labor and Delivery
1,000 cc 5% D/LR
May ambulate
Type and screen
CBC
May have ice chips
2/5 Discharge patient to home
_________________
DELIVERY RECORD

DATE: 2/3

The patient was 3 cm dilated when admitted. The duration of the first stage of labor was 6 hours, second stage was 14 minutes, third stage was 5 minutes. She was given local anesthesia. An episiotomy was performed with repair. There were no lacerations. The cord was wrapped once around the baby's neck, but did not cause compression. The mother and liveborn baby were discharged from the delivery room in good condition.
________________
LAB REPORT

HEMATOLOGY

DATE: 2/3

Specimen Results Normal Values
WBC

5.2

4.3-11.0

RBC

4.9

4.5-5.9

HGB

13.8

13.5-17.5

HCT

45

41-52

MCV

93

80-100

MCHC

41

31-57

PLT

255

150-450
___________
Enter four diagnosis codes and one procedure code.

PDX

DX2

DX3

DX4

PP1
AMBULATORY CASE

Candidates will need to click on each tab to review the reports. Candidates will be instructed on exactly how many codes are required. The key will be displayed as to which codes are required, meaning Diagnosis or Procedure and how many. In this sample question, the case requires 1 Diagnosis code and 1 Procedure code. If the candidate gets both codes correct they will receive two (2) points. If they get one (1) correct and one (1) incorrect they will receive 1 point. If candidate does not enter an answer in one of the required boxes they will not be allowed to move to the next medical record case.
-----
FACESHEET
DATE OF ADMISSION: 4/5 DATE OF DISCHARGE: 4/5

SEX: Male AGE: 37 DISCHARGE DISPOSITION: Home

ADMISSION DIAGNOSIS: Left inguinal hernia

DISCHARGE DIAGNOSIS: Same

PROCEDURES: Left inguinal herniorrhaphy with excision of lipoma of spermatic cord
--------
H&P
ADMITTED: 4/5

HISTORY OF PRESENT ILLNESS: The patient has been well until several months ago when he began to have pain when lifting.

PAST MEDICAL HISTORY: The patient has no other significant medical or surgical history.

SOCIAL HISTORY: Does not use alcohol or tobacco.

ALLERGIES: No known allergies

MEDICATIONS: None

REVIEW OF SYSTEMS:

SKIN: Warm and dry, mucous membranes moist

HEENT: Essentially normal

LUNGS: Clear to percussion and auscultation

HEART: Normal, regular rhythm

ABDOMEN: Normal

GENITALIA: Palpable mass in inguinal canal

RECTAL: Normal

EXTREMITIES: No edema

NEUROLOGIC: Deep tendon reflexes normal

IMPRESSION: Left inguinal hernia

PLAN: Surgical repair of inguinal hernia
--------
PROGRESS NOTES

DATE NOTE
4/5 Nursing:
Betadine scrub performed, patient anxious to get surgery over; preoperative medications given as ordered.
4/5 Attending MD:
Brief op note
Dx: Left inguinal hernia
Px: Left inguinal herniorrhaphy
Anes: Local plus sedation
Complications: None
4/5 Attending MD:
No bleeding; patient okay for discharge.
___________
OPERATIVE REPORT

DATE: 4/5

PREOPERATIVE DIAGNOSIS: Left direct inguinal hernia

POSTOPERATIVE DIAGNOSIS: Left direct inguinal hernia

OPERATION: Left inguinal herniorrhaphy

ANESTHESIA: Local plus sedation

OPERATIVE INDICATIONS: A wide mouth direct sac was present in the lower inguinal canal. A lipoma of the cord was present, but no indirect sac.

OPERATIVE PROCEDURE: Under local anesthesia consisting of the equivalent of 19 cc of 1% Xylocaine and 8 cc of 0.5% Marcaine, the abdomen was prepared with Betadine and sterilely draped. A left inguinal incision was made and carried down through subcutaneous tissues to the aponeurosis of the external oblique, which was opened from the external ring to a point over the internal ring. Flaps were cleaned in both directions. The nerve was retracted inferiorly. The cord structures were separated from the surrounding at the level of the pubic tubercle and retracted with a Penrose drain. Cremaster over the cord was opened and a search made for an indirect sac. None was found. Lipoma of the cord was dissected free and clamped at its base and excised. The base was ligated with 00 chromic catgut. Additional cremasteric muscles were divided and ligated with 00 chromic catgut. The direct sac was further dissected down to its base and inverted as the defect was closed by approximating transversus to transversus with a running suture of 00 Vicryl. The floor of the canal was then closed by approximating the internal oblique to the shelving portion of the inguinal ligament with multiple sutures of 0 Ethibond. The external oblique aponeurosis was then reclosed with 0 Ethibond, leaving the cord and nerve in the subcutaneous position. Several sutures of 0 Ethibond were also placed above the emergence of the cord at the internal ring. Subcutaneous tissues were then approximated with 3-0 Vicryl and after irrigation skin was closed with skin clips. The patient tolerated the procedure well and was sent to the recovery room in good condition.
---------
PATH REPORT

DATE SPECIMEN SUBMITTED: 4/5

SPECIMEN: Lipoma of cord

CLINICAL DATA:

GROSS DESCRIPTION: The specimen is submitted as lipoma of cord. It consists of a single irregularly shaped fragment of fatty tissue that is 8.0 × 4.0 × 1.5 cm. It is covered with a thin membrane.

MICROSCOPIC DESCRIPTION:

DIAGNOSIS: Lipomatous tissue of left spermatic cord
____________
PHYSICIANS ORDER

DATE ORDER
4/5 Attending MD:
Admit to same-day surgery
Betadine scrub ×3 Preop
May take own meds
4/5 Anesthesia note:
Continue NPO
Demerol 50 mg IM 1½ hr Preop
Vistaril 50 mg IM 1½ hr Preop
Atropine 0.4 mg IM 1½ hr Preop
4/5 Attending MD:
Vital signs q. 15 min until stable
Regular diet
Darvocet-N-100 q. 4 hrs p.r.n. pain
Discharge to home when stable
-------------
HEMATOLOGY

DATE: 4/5

Specimen Results Normal Values
WBC

6.83

4.3-11.0

RBC

4.57

4.5-5.9

HGB

13.7

13.5-17.5

HCT

43

41-52

MCV

87.0

80-100

MCHC

35

31-57

PLT

300

150-400

AUTO DIFFERENTIAL

DATE: 4/5

Specimen Results Normal Values
NEUT

68.3

40.0-74.0

LYMPH

20

19.0-48.0

MONO

5.6

3.4-9.0

EOS

5.6

0.0-7.0

BASO

0.6

0.0-1.5

LUC

3.8

0.0-4.0

URINALYSIS

DATE: 4/5

Test Result Ref Range
SP GRAVITY

1.017

1.005-1.035

PH

6

5-7

PROT

TRACE

NEG

GLUC

NONE

NEG

KETONES

NONE

NEG

BILI

NONE

NEG

BLOOD

TRACE

NEG

NITRATES

NONE

NEG

RBCS

NONE

NEG

WBCS

NONE

NEG
-----------
RAD REPORT

DATE: 4/5

DIAGNOSIS: Inguinal hernia

EXAMINATION: Chest x-ray

Heart size and shape are acceptable. The lung fields are clear and the pulmonary vascular pattern is unremarkable. There is no free fluid and the trachea remains midline.
-----------
Enter two diagnosis codes and two procedure codes.

PDX

DX2

PP1

PR2