Question

1.1 LOCATION: Inpatient, Hospital PATIENT: Elaine Snow PHYSICIAN: Andy Martinez, M.D. ADMITTING DIAGNOSIS: Endometrial hyperplasia and postmenopausal bleeding. DISCHARGE DIAGNOSES: 1. Adenomatous endometrial hyperplasia. 2. Intramural and subserosal leiomyomata. 3. Hypertension. PROCEDURE PERFORMED: Total abdominal hysterectomy with bilateral salpingo-oophorectomy carried out. COMPLICATIONS: Bleeding from small bowel mesentery, oversewn by Dr White at the time of procedure. HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old woman who had been seen with complaints of postmenopausal bleeding. Dilation and curettage had been carried out and showed evidence of endometrial polyp along with simple endometrial hyperplasia without atypia. Due to the hyperplasia, Elaine was started on high dose Progesterone therapy with 20 mg daily. Unfortunately, she developed very heavy irregular bleeding on this and therefore elected to undergo definitive therapy in the form of total abdominal hysterectomy with bilateral salpingo-oophorectomy. HOSPITAL COURSE: The patient was admitted on January 19, and I performed her total abdominal hysterectomy with bilateral salpingo-oophorectomy. During the course of the procedure, there was some bleeding noted from the small bowel mesentery. Dr. White was consulted intraoperatively, and he oversewed the bleeding area using figure-of-eight suture. The procedure was otherwise uncomplicated, and estimated blood loss was 350 cc. The patient had then a completely uncomplicated postoperative course. By the second postoperative day she was feeling well enough to go home. She was eating and passing flatus and ambulating on her own. She had adequate pain control with Ibuprofen alone. DISCHARGE INSTRUCTIONS: The patient was instructed to avoid abdominal and pelvic strain for six weeks. She was to return to clinic in one week for staple removal. Pathology report subsequently showed adenomatous hyperplasia of the endometrium and multiple intramural and subserosal leiomyomata. DISCHARGE MEDICATIONS: 1. Ibuprofen 600 mg p.o q 6 to 8 hours p.r.n. 2. Ferrous sulfate 325 mg p.o tid. 3. Peri-Colace 200 mg p.o q h.s. p.r.n. 1.2 LOCATION: Inpatient, Hospital PATIENT: Jody Newark PHYSICIAN: Kevin White, M.D. This is a 34-year-old white female who came in complaining of right upper quadrant abdominal pain and also had some elevated liver function tests consistent with choledocholithiasis. Endoscopic retrograde cholangiopancreatography was performed revealing only sludge within the common bile duct. After the endoscopic retrograde cholangiopancreatography was performed, a laparoscopic cholecystectomy was able to be performed and was performed without any trouble. The patient did very well postoperatively and no longer has any of the pain she previously had. She is eating well and ambulating well and ready for discharge. PRIMARY DIAGNOSIS: Acute cholecystitis and choledocholithiasis. PRINCIPAL PROCEDURES PERFORMED: Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. SECONDARY DIAGNOSIS: Hypertension. ALLERGIES: No known drug allergies. ACTIVITY: As tolerated. No lifting greater than 15 pounds in the next two to three weeks. The patient is to follow-up with Dr. White in two weeks regarding gallbladder removal and follow-up with Dr. Gaul concerning her hypertension. MEDICATIONS: Darvocet-N 100 one to two tablets p.o. q 4 to 6 hours p.r.n. pain with 30 being given and Hyzaar as prescribed as a home medication. 1.3 LOCATION: Inpatient, Hospital PATIENT: Etta Flagstone ATTENDING PHYSICIAN: Gregory Dawson, M.D. Surgery operator paged me to be on standby for Cardiology. The patient is a 76-year-old female who was having a PTCA/Stent of right coronary artery due to atherosclerotic heart disease. I arrived to the operative suite at 7:30 AM. I stayed in the suite until I was notified by one of the surgical team members that I was not needed at 8:20 AM. No other services were performed by me during this time. 1.4 LOCATION: Outpatient, Clinic PATIENT: Julia Jones PHYSICIAN: Frank Gaul, M.D. CHIEF COMPLAINT: Hip pain. SUBJECTIVE: This is a 42-year-old Caucasian female who presents to the clinic today to establish with me as her primary care provider. At this particular visit she is complaining of right hip pain and would also like to be weaned off her Zoloft because she is thinking that this is contributing to her increase in weight. She also complains of a nagging dry cough and would like to find out what might possibly be causing that. Her right hip pain has been going on for about three months now, which is constant and is aggravated by standing up from sitting. She does not feel the pain as much when walking and she says that this pain sometimes radiates to the buttocks and all the way down to her heel area. She occasionally feels a tingling sensation at the lateral aspect of the thigh, particularly at night. She has been treating this with over-the-counter pain medication but has not found it to be helpful. In terms of her cough, she noticed that she usually gets this whenever she has heartburn. She also thought that it might be related to her smoking as well. PAST MEDICAL HISTORY is remarkable for: 1. Gastroesphageal reflux disease and has been taking medication for this but she cannot recall the name of that medication right now. 2. She also was found to have only one kidney and this was thought to be congenital. 3. Obesity. PAST SURGICAL HISTORY is remarkable for a hysterectomy due to a bicornuate uterus. PSYCHIATRIC HISTORY: She suffered from a major depressive disorder and anxiety. SCREENINGS: She gets a Pap smear and mammogram every year. Last time was last year, which were normal. CURRENT MEDICATIONS: 1. Aspirin 81 mg daily. 2. Tums as needed. 3. Zoloft 100 mg daily. ALLERGIES: She otherwise has no known drug allergies. FAMILY MEDICAL HISTORY: Her father died at the age of 70 from a myocardial infarction. Mother is presently having high blood pressure and is taking medication for her heart. She also has high blood cholesterol. She is presently 67 years old. There is one brother who has ankylosing spondylosis. She has a total of three sisters. One sister has a benign breast tumor. PERSONAL AND SOCIAL HISTORY: She is married. She has been doing current job for about 11 years now. She smokes and currently one pack will last her about two weeks. She denies alcohol use. I have established a quitting date of smoking with her. She has a total of two children. One is 18 years old and one is 6 years old. She had a miscarriage and one stillbirth. She does not particularly exercise but has been watching her diet, drinking Slim-Fast once a day, and following Weight Watchers. REVIEW OF SYSTEMS: Constitutional, head and neck, chest and lungs, cardiovascular, gastrointestinal, genitourinary, and extremities are as mentioned above. All others are negative. OBJECTIVE FINDINGS: Vital signs: Blood pressure is 110/70. Pulse rate of 88. Weight is 196 pounds. General survey: She is a middle-aged lady who is pleasant and in no acute distress. Head and neck: Normocephalic and atraumatic. Pink conjunctivae. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Neck is supple. No jugular venous distention. No carotid bruit. No thyromegaly. No cervical lymphadenopathy. Chest and lungs: Symmetrical expansion. Clear breath sounds. No rales or wheezes. Cardiovascular: Normal rate and regular rhythm. No murmur and no gallop. Abdomen is obese, soft; normoactive bowel sounds; nontender. No organomegaly. Extremities: She has no edema, cyanosis, or clubbing. Palpable distal pulses. Straight-leg raise testing on both lower extremities is essentially negative. She has pain on internal rotation of the right hip joint. No pain on external rotation. On the left side internal and external rotation of the hip joints are negative. ASSESSMENT/PLAN: 1. Hip pain, exact etiology is uncertain but this could be most likely secondary to degenerative joint disease of the hip versus mild trochanteric bursitis. Superficial femoral nerve syndrome is also a consideration but not very likely. Discussed management with patient and we will just continue to observe for now. I advised her to give us a call when she develops progression of symptoms and referral to Orthopedics might be appropriate if that happens. 2. Cough, dry, probably related to heartburn symptoms. Advised her to elevate her bed at night and continue to take a proton pump inhibitor for heartburn and also to quit smoking at our established quitting day, nicotine dependence. 3. Major depressive disorder, presently stable. She wants to be weaned off Zoloft and we are therefore decreasing her dose to 50 mg in the next two weeks and 25 mg after that. Then we will just discontinue it after one month. She agrees to this plan. She does not need to come to the clinic unless there is a new concern. Her next possible visit would be one year from now. 1.5 LOCATION: Outpatient, Clinic PATIENT: Mary Springfield ATTENDING PHYSICIAN: Frank Gaul, M.D. This is a 42-year-old female who has been disabled due to work-related injury for about 8 months now. She is unable to use her hands or arms in any type of lifting due to bilateral carpal tunnel syndrome and chronic pain. The patient states even simple household chores is painful. The patient's pain level today is 8 out of 10. She will continue with her prescribed medication at the current dosage. I will also consult Dr. Barneswell in physical therapy to strengthen her arms. I will see this patient back after her first treatment in therapy. I need all the codes in each part

Answer 1

Case 1:

Endometrial hyperplasia: N85.00

Postmenopausal bleeding: N95.0

Intramural leiomyoma: D25.1

Subserosal leiomyoma: D25.2

Hypertension: I10

Total abdominal hysterectomy with bilateral salpingo-oophorectomy: 58954.

Bleeding from small bowel mesentery: K55.0

Dilation and curettage: 58120

Staple removal: 99024

Case 2:

Right upper quadrant abdominal pain: R10.11

Elevated liver function tests: R94.5

Choledocholithiasis: K80.50

Endoscopic retrograde cholangiopancreatography: 43260

Laparoscopic cholecystectomy : 47562

Acute cholecystitis: K81.0

Hypertension: I10

Case 3:

PTCA/Stent of right coronary artery : Z95.5

Atherosclerotic heart disease: I25.10

Case 4:

Right hip pain : M25.551

Gastroesphageal reflux disease : K21.9

Obesity: E66.9

Hysterectomy: 58570

Bicornuate uterus: Q51.3

Major depressive disorder: F32.9

Anxiety: F41.9

Pap smear: 88141

Mammogram: 77057

Myocardial infarction: I21.9

Hypertension: I10

High blood cholesterol: E78.5

Ankylosing spondylosis: M45

Benign breast tumor: D24.9

Miscarriage: O03.9

Stillbirth: Z37.1

Degenerative joint disease of the hip: M16.11

Mild trochanteric bursitis: M70.61

Case 5:

Disabled: Z02.71

Bilateral carpal tunnel syndrome: G56.03

Chronic pain: G89.4