ICD-10-CM Chapter 6 Outpatient and Physician Office Coding

SUBJECTIVE: 20-year-old female patient with past medical history significant for asthma underwent total thyroidectomy due to feelings of fatigue and weight gain for the past six months. OBJECTIVE: Thyroid function tests revealed that the patient was hypothyroid with a thyroid-stimulating hormone level of 110.2, free thyroxine index of 0.9, and total T3 of 0.41. The patient also has a palpable mass in the left lobe of the thyroid, and thyroid ultrasound revealed diffuse enlargement of the thyroid gland and microcalcifications. Thyroid lobes were biopsied bilaterally; and based on those results, the patient underwent total thyroidectomy. DIAGNOSES: Hypothyroidism. Enlargement of thyroid gland. History of asthma.

E03.9, E04.9, Z87.09

This 51-year-old white female has noticed a steady enlargement on the left side of the neck for the past year. A thyroid scan revealed a cold nodule in the right lobe, and carcinoma is to be ruled out. The patient also complains of some difficulty with pain in the neck and on swallowing. PHYSICAL EXAMINATION reveals a large mass in the left lobe of the thyroid and a questionable mass on the right side. The patient was taken to surgery, where at the time of exploration, both lobes of the thyroid were markedly enlarged and revealed multiple nodules. A total thyroidectomy was performed after identifying the parathyroid glands and protecting them. The patient was discharged and instructed to return for follow-up examination within 2 weeks. She was placed on Synthroid 0.15 daily and no other medication. DIAGNOSES: Nodular colloid goiter, left and right lobes of thyroid. Degenerating follicular adenoma, right lobe of thyroid.

E04.9, D34

A 54-year-old male previously diagnosed with arteriosclerotic heart disease (ASHD) undergoes scheduled right and left cardiac catheterization as an outpatient. The patient has no past history of previous coronary artery bypass graft (CABG) surgery. Cardiac catheterization results revealed 40% blockage of the right coronary artery, 70% blockage of the left main coronary artery, and 80% blockage of the left anterior descending coronary artery. Surgical intervention options to treat the blockages were discussed with the patient, and the patient will be admitted in two days to undergo triple CABG.

I25.10

A 62-year-old patient with known congestive heart failure registers for outpatient services at the heart failure clinic and receives lifestyle modification counseling about his diet and activities. He received instruction from the dietician about following a low-sodium, low-fat diet, and he was also counseled to avoid tobacco and heavy alcohol use. His current medications were reviewed, and his diuretic dosage was adjusted.

I50.9, Z71.3

This 5-year-old white male is admitted with the chief complaint of recurrent bouts of tonsillitis and tonsils so large that foods get stuck in them and he chokes on it. He has had a sore throat now for 4 to 5 weeks, and this is the second time this year that this has happened. He has consulted Dr. Blair, and she advised that the patient undergo tonsillectomy and adenoidectomy (T&A). The patient has no ear problems, and he has not had strep throat that his father knows of. PAST MEDICAL HISTORY: He has had no operations, serious illnesses, or injuries. FAMILY HISTORY: He has had no familial diseases such as cancer, tuberculosis, epilepsy, diabetes, bleeding tendency, or heart attacks. SOCIAL HISTORY: The patient is in kindergarten. He lives with his parents and has no social problems. SYSTEMIC REVIEW: The father states that his son has been in good health and has had no other problems. PHYSICAL EXAMINATION: Reveals his tonsils to be huge. There is evidence that he had an anterior lymphadenopathy. LABORATORY STUDIES: Urinalysis negative. Bleeding time 1 minute 30 seconds. Partial prothrombin time 30 seconds. Hemoglobin 12.3 grams, hematocrit 37 volume percent, white blood count 6,500 with 34 polys. Chest x-ray normal. The patient was prepared for surgery and taken to the operating room where, under satisfactory general intratracheal anesthesia, T&A was performed. Following the operation, he had an uncomplicated postoperative recovery. He had no bleeding, he was afebrile, tonsillar fossa are clean, and he has had no anesthetic complications. DIAGNOSIS: Greatly hypertrophied tonsils and adenoids.

J35.3

SUBJECTIVE: This 48-year-old man is a patient of mine who complains of midsternal chest pain but no radiation. This has occurred intermittently today since 10 p.m. and did not occur reliably with exertion. He has not been exerting himself too much, as he is a pastor at a Baptist church in Alfred. He complains of feeling quite warm, but has had no diaphoresis or shortness of breath. He previously had his gallbladder removed. He has been taking Inderal 40 milligrams four times each day, and he took Isordil sublingually with mixed results during the day today. He says that Tylenol will help somewhat with the pain in the midsternal area. OBJECTIVE: Physical examination reveals a mildly anxious middle-aged male in little distress. The neck is supple; carotids are two plus without bruits. Chest is symmetrical in expansion, and lungs show few abnormal sounds and some rales in the right base. Heart is regular rate and rhythm; S1 and S2 and 2/4; no murmurs, clicks, heaves, gallops, or rubs were appreciated. The abdomen is soft and nontender. There is a right upper quadrant surgical scar; no masses or organomegaly noted. EKG was done and read as normal. Chest x-ray shows slightly increased density at right lower lobe. He was given Mylanta without any change in his pain. DIAGNOSIS: Bronchitis and early pneumonia on the right.

J40, J18.9

SUBJECTIVE: 42-year-old female with past family history of gastric polyposis underwent upper gastrointestinal endoscopy, which revealed multiple gastric polyps in the fundus and body. OBJECTIVE: Biopsies of the gastric polyps were submitted for pathological examination. DIAGNOSIS: Multiple gastric (stomach) polyps. Family history of gastric polyposis

K31.7, Z83.79

53-year-old male admitted with a right inguinal hernia. Laboratory results were within normal limits. Right inguinal herniorrhaphy was performed, and the patient did well; there were no complications. He was discharged to be seen in the office in several days for suture removal. No specific diet or medication was prescribed. The patient was advised to avoid any strenuous activities. DIAGNOSIS: Right inguinal hernia.

K40.90

This 48-year-old male patient has had an anal fissure for several months and is complaining of pain and bleeding. This has not responded to conservative measures, and he is scheduled to undergo outpatient fissurectomy and hemorrhoidectomy. PHYSICAL EXAM reveals no other pertinent positive findings except the presence of obesity, anal fissure, and hemorrhoids. X-ray of the chest was unremarkable. Barium enema studies were unremarkable. EKG showed no abnormality. Lab results revealed blood sugar 92, BUN 14, normal electrolytes and normal enzymes. CBC and differential were normal. Urinalysis was essentially unremarkable. After adequate work-up, the patient was taken to surgery; and under endotracheal anesthesia, a fissurectomy, hemorrhoidectomy, and sphincterotomy were performed. Postop, the patient was voiding and comfortable. The patient was prescribed Tylenol with Codeine, Metamucil, sitz baths, and limited activity. The patient will be followed in my office. DIAGNOSES: Anal fissure. First-degree bleeding hemorrhoids.

K60.2, K64.0

Gallbladder cholecystogram shows moderate concentration of dye in the gallbladder, no evidence of stone, and moderate hypertrophic change of lumbar spine. Small intestinal pattern is normal below the level of the duodenum. Impression is hypertrophic gallbladder with no diagnostic evidence of stones.

K82.8

Patient underwent upper gastrointestinal study due to severe stomach pain. Study reveals esophagus and stomach to be normal in appearance, and first portion of duodenum is normal. There is moderate deformity of the medial aspect of the second portion of the duodenum with moderate flattening of the mucosal pattern in this area, but without any definite evidence of ulceration. The duodenal loop is not significantly widened, but there does appear to be slight extrinsic pressure and probable stiffening of the medial wall of the second portion of the duodenum. IMPRESSION: Second portion of duodenum is consistent with residues of recurrent pancreatitis with probable exacerbation of the pancreatitis at this time. The possibility of neoplasm arising in the head of the pancreas is not excluded.

K86.1

The patient is a 41-year-old male seen for treatment of a scratch on the dorsum of his right hand that occurred about a week ago. It didn't seem to bother him, and he didn't think too much of it. He dropped a board on it about two days ago, and it stung a little bit and became a little swollen. It was rather tender today and looking a bit red. He was quite concerned because he has had blood poisoning once before with an infected hair follicle on his hand. I instructed him to come to the urgent care center for evaluation. The patient does have swelling and induration around the area where he had the original scratch. It is red and warm, but there is no streaking that I can see in the lymphatic channels. I think he is developing an infection there, or cellulitis. IMPRESSION: Cellulitis, right hand. (Initial encounter.) DISPOSITION: Hot soaks three or four times each day. Amoxil 250 milligrams three times each day for a week. If it should progressively worsen and become more swollen, the patient should call and have it checked again to be sure he isn't developing an abscess; otherwise, we'll give him a few days. If it hasn't cleared within 5 to 7 days, he is to let me know.

L03.113, W20.8xxA, Y92.9, Y99.9, Z86.2

This 15-year-old male presents to the urgent care center with the complaint of a cyst on his right cheek. Over the past two days, the patient has developed a reddened, tender mass on the right cheek, just lateral to the nose. Physical exam reveals an erythematous, tender mass approximately 7 millimeters in diameter on the right cheek. It is hard and tender, but does not seem to be fluctuant at this time. DIAGNOSIS: Infected sebaceous cyst, right cheek. PLAN: The patient was instructed to use warm soaks frequently, and he was given a prescription for tetracycline 250 milligrams four times daily. He was instructed to see Dr. Smith in two days. He is to return sooner if he has further difficulty.

L72.3

Patient underwent opaque right knee arthrogram for severe pain and limited mobility. Following shaving and scrubbing of the knee in the usual manner, local anesthetic was infiltrated along the lateral approach to the patellofemoral joint. A needle was directed through the anesthetized tissue and into the joint with subsequent removal of 30 cc of pink-colored joint fluid. Then, 11 cc of Renografin 76 were injected and films taken in various projections. Fissures are demonstrated in the posterior segment of the medial meniscus. Cruciate ligaments and lateral meniscus appear intact. Impression is knee joint effusion and rupture of posterior segment of right medial meniscus. (Initial encounter.)

M25.461, S83.241A

SUBJECTIVE: 25-year-old male was working with a heavy sledgehammer in the garden on his personal property when he noted pain in his right shoulder area. The pain developed suddenly as he was swinging the hammer rather vigorously. The pain has persisted over the past three weeks. At certain times, it was somewhat better; but it became painful once again. The patient has continued working, which involves swinging this sledgehammer. OBJECTIVE: Physical examination reveals tenderness over the anterior joint line; there is no swelling or abnormal mass present. The rotator cuff does not seem involved, as the patient can tolerate extreme downward pressure on his elbows without any pain whatsoever. What really causes the patient's pain is bringing the arms apart when they are in the midline in front of his chest. Distal neurovascular status is intact. X-ray of the shoulder was negative. DIAGNOSIS: Pain, right shoulder. Probable strain, deltoid muscle, and possibly the deeper muscles of the anterior shoulder area. TREATMENT: The patient was given a prescription for Motrin 600 milligrams three times daily and advised to apply heat to the area once or twice each day. He is also to rest the arm as much as possible; however, he says he must work and will not take time off. He was told that this pain may last for a number of weeks before it resolves completely. He is to return to see Dr. Callus if there are any problems.

M25.511, Y93.H2, Y92.007, Y99.8

A 42-year-old male patient diagnosed with systemic lupus erythematosus receives a scheduled transfusion of erythrocytes and platelets in the ambulatory transfusion clinic.

M32.9

This 44-year-old male presents with a chief complaint of back pain. HPI: 44-year-old gentleman states that he went fishing Wednesday. He did not fall or injure himself, but Thursday he was feeling quite bad with right flank pain radiating into the back of his leg and into the testicle. He stated that he had no change in the color of his urine and that the pain actually started to subside. Friday he had another recurrence of pain, and it gradually worsened and stayed with him. Today it was much worse, he was unable to work, and he came to the urgent care center for evaluation and treatment. The patient walks leaning to the right where his pain is. He has a significant amount of difficulty in hyperextension and also forward bending. It does not hurt him too much to bend to the right, but it hurts him quite a bit to bend to the left. He has a lot of tenderness in the sacroiliac region and also in the superior rim of the ilium and the sacrum. X-rays of the area appear normal to my eye. The radiology report is not back at this time. PLAN: We will treat him with Tylenol with Codeine, two every four hours as needed, and Flexeril 10 milligrams three times a day. He should not work tomorrow or Monday, and perhaps he will be able to return to work on Tuesday. He was instructed to call the urgent care center if he gets any worse. He is instructed to schedule a follow-up visit in one week. He left the urgency care center in satisfactory condition. DIAGNOSIS: Sacroiliac inflammation.

M46.1

A 77-year-old individual experiences neck pain and seeks chiropractic treatment. Upon examination, all neurological signs are normal. There is restricted joint motion and tight muscles along both sides of the neck and into the upper and midback. Previous x-ray of the neck revealed osteoarthritis. The patient undergoes chiropractic treatment. DIAGNOSIS: Osteoarthritis, cervical spine.

M47.892

A 37-year-old civilian contractor was hired by a home owner. While lifting boards from his truck while on the job in the private driveway at a single family residence and began to experience acute burning pain in his neck from this sudden strenuous movement. His symptoms persisted; and he was seen by his chiropractor, who checked the range of motion in his neck and noted restriction in lateral bending and rotation. Neurological screening revealed decreased sensation at the left thumb and first finger. Reflexes were normal (intact), but there was some muscle weakness in the arm. Patient underwent magnetic resonance imaging (MRI), which was negative, and received chiropractic treatment. DIAGNOSIS: Cervical disc syndrome.

M50.10, Y93.H3, Y92.014, Y99.0

This 1-year-old little girl injured her hand while "playing the drum" by banging away at pots and pans on the floor of the kitchen while her mother was nearby preparing last evening's meal. The child slept fitfully last night, and this morning her left hand is somewhat swollen and painful to touch. X-ray was taken and is negative for fracture. I treated her with a sling, ice, and elevation, which will continue at home. She will be rechecked as needed. She left the office in good condition.

M79.89, M79.642, W22.8xxA, Y92.010, Y99.8

A 50-year-old male patient underwent ultrasound of neck and ultrasound guided placement of internal jugular dialysis catheter. Indication for radiographic procedures is chronic renal failure and occluded dialysis access graft. Real-time ultrasound examination was done of the neck and showed patency of both internal jugular veins. Following sterile prep and drape and infiltration with local anesthetic, puncture was done of the lower aspect of the right internal jugular vein using a 21-gauge needle. Using Seldinger technique, the tract was dilated and a 14 French dialysis catheter was introduced and positioned within the right atrium. The catheter was secured with a silk suture and irrigated and the patient sent for dialysis.

N18.9, T82.898A

This is an 89-year-old white male who was apparently in good health except for pneumonia in 1938 and had never had any serious medical problems since then. For about a month prior to outpatient surgery, he developed urgency and frequency upon urination and marked nocturia every hour, followed finally by the passing of blood in the urine. He was seen in the emergency room (ER) last week due to passing blood in the urine every day for several days and having a great deal of difficulty voiding. ER treatment involved inserting a Foley catheter, from which 400 cc of grossly bloody urine was evacuated. PHYSICAL EXAMINATION: Reveals a degree of blindness due to cataracts. The testes are atrophic. Prostate is a grade II benign, enlarged gland. LABORATORY AND X-RAY FINDINGS: BUN 62, blood sugar 155, CO2 14, creatinine 3.6. Urinalysis reveals many red blood cells per high-power field and WBC 4-6. Urine culture reveals innumerable enterococcus. Complete blood count reveals hemoglobin of 11.9 grams, hematocrit of 35. Blood gases reveal pH of 7.38, PCO2 of 22.9, PO2 of 91, HCO of 313. WBC of 12,200. EKG was negative. Drip infusion IVP revealed poorly functioning kidneys and one bladder diverticulum with elevation of the bladder floor consistent with a large prostate gland. Chest x-ray showed bilateral basal pulmonary infiltration and calcification of the thoracic aorta. Upper gastrointestinal and gallbladder series and small bowel series revealed small active ulcer crater of the lesser curvature of the pyloric canal. Patient underwent cystoscopy and retropubic prostatectomy. DIAGNOSES: Benign prostatic hypertrophy. Chronic renal insufficiency secondary to benign prostatic hypertrophy. Urinary tract infection.

N40.1, N18.9, N39.0, B95.2, R35.0, R39.15

This 34-year-old male, who has had a hydrocele in the past and had been seen and treated by Dr. Wise, returns now for continued pain and swelling in the hydrocele, which is causing poor sleep habits. Apparently, the patient has been given some kind of fluid pill for the discomfort. OBJECTIVE: Patient has a tender, swelling right scrotal region about the size of a grapefruit, which is very tense. ASSESSMENT: Right-sided hydrocele. PLAN: The patient is to wear tight, supportive underwear; take Tylenol #3 for pain; and see Dr. Wise for evaluation.

N43.3

Patient was diagnosed as missed abortion at 20 weeks' gestation. The patient was noted to have grown appreciably in the last month of her prenatal care, and it was noted that she had begun bleeding 3 days before being seen in the office yesterday. At the time of the office visit, she was passing clots. The cervix was dilated, and she was developing a foul-smelling discharge but no morbidity. She was scheduled for outpatient surgery, during which pregnancy was removed with curettage of the uterus; and the patient was discharged in satisfactory condition. Her hemoglobin was 13.8 gm, white blood cell count was normal differential. Pathology revealed products of conception and degenerated decidual and placental tissue. DIAGNOSIS: Missed abortion.

O02.1

This young lady was accidentally hit in her nose and mouth two days ago by another resident; she has had intermittent nosebleeds since that time. She is residing at the detention center here in the village and was brought to the urgent care center and examined. There was moderate swelling in the nose and quite a bit of edema and swelling in the nasal mucosa, but there is no active bleeding noted at the present time. No treatment was given other than Dimetapp one every 12 hours, and the patient was told to avoid taking aspirin. She is to take Tylenol and apply ice to her nose. The detention center staff person who accompanied the patient to the urgent care center was told to call if the patient experienced further problems.

R04.0, W50.0xxA, Y92.9, Y99.9

Patient underwent excretory urogram for complaints of urinary incontinence. Urogram revealed that both kidneys appear to concentrate Renografin media in a satisfactory manner. Renal collecting system on the left appears grossly normal. Visualized lateral contour of right kidney appears normal. Renal pelvis and ureters are of normal caliber. Urinary bladder is moderately distended, normal in contour, and shows some indentation on its dome, probably due to the adjacent uterus. There is moderate post-voiding residual. Impression is normal right and left calices, small post-voiding residual with indentation on dome of urinary bladder possibly due to an enlarged uterus.

R32

SUBJECTIVE: 15-year-old male patient with previous diagnoses of congenital cataracts and retinal detachments had experienced an episode of orbital hemorrhage, which was treated in the past. He arrived in the ED today after developing pain behind his right eye yesterday. OBJECTIVE: Physical examination revealed no redness of the eye. The left pupil is deviated medially with a steamy anterior chamber. This is the normal appearance, according to the mother. There was no sight in that eye. Funduscopic exam shows a pigmented retina in the right eye, but no evidence of hemorrhage or optic disc cupping. Schiotz tonometry showed a right orbital pressure of 21 and left orbital pressure of 0. There was no cervical lymphadenopathy. Tympanic membranes were clear. Chest was clear, and heart is regular rate and rhythm. There is full range of motion of the neck. No palpable temporal arteries; no abrasions or swelling. There has been no fever. ASSESSMENT: Headache, etiology unknown. PLAN: I called his primary care physician, who explained that this has been a problem in the past and that neurologically, the patient has been evaluated for this type of problem but nothing was ever found. He believed that the pressure of 21 was okay and that the patient could be discharged on some sort of analgesic. The patient is scheduled to be seen by him in two weeks. DIAGNOSIS: Headache.

R51

This 38-year-old man was accidentally poked in his left eye by his 9-month-old little girl yesterday when she came to visit him in his office on a college campus, where he teaches. He says that she was very excited about seeing him and when she reached up to be lifted into his arms, her finger accidentally poked him in the eye and her fingernail scratched his eyeball. He had to teach a class after he saw her, or he would have been in my office earlier. He states, "My eye is killing me!" Since that time, he has pain in his left eye and a lot of watering. He has had no changes in vision, no blurriness noted, and he is otherwise well. Physical examination shows the conjunctiva to be inflammed. Funduscopic examination is normal, and extraocular movements are intact. Stain with fluorescein shows positive corneal abrasion. I administered an ophthalmic topical analgesic to relieve his discomfort and Chloromycetin ointment to the eye to prevent infection. He was fitted with an eye patch, and he is to see me tomorrow for a recheck. DIAGNOSIS: Corneal laceration.

S05.32xA, W50.4xxA, Y92.214, Y99.8

A 15-year-old high school student was playing in a basketball game one evening in the gymnasium at his public high school; and when he went up for a rebound, he collided with another player. He felt his neck "wrench" backward, and he experienced immediate pain in both sides of his neck. That evening he felt pain and stiffness in his neck, and he had trouble turning his head. DIAGNOSIS: Acute cervical sprain. (Initial encounter.)

S13.4xxA, W51.xxxA, Y93.67, Y92.310, Y92.213, Y99.8

A 25-year-old college student is seen for chiropractic treatment. She complains of neck stiffness, shoulder and back pain, and headaches. Neck x-rays are negative. Chiropractic treatment included adjustment and heat therapy. DIAGNOSIS: Neck sprain. (Initial encounter.)

S13.9xxA

A 48-year-old online college professor who sits at a computer all day in her office at the college has been experiencing neck pain accompanied by soreness and stiffness in her upper back. She became concerned when she began to experience numbness and tingling in her left arm, especially at night. History reveals no weakness in her arms and minor arm pain. All neurological signs are normal, and the patient has full range of motion in her neck except for some restriction when she bends her head to the left. Tight and very tender muscles in the upper back and along both side of the neck are palpated. There are also joint restrictions in the middle back. Chiropractic treatment was provided. DIAGNOSIS: Cervical neck strain. Myalgia, upper back.

S16.1xxA, M79.1, Y93.C1, Y92.214, Y99.0

SUBJECTIVE: A 45-year-old female was seen complaining of severe pain of the right knee and ankle after having been in a motorcycle accident earlier today. She has difficulty bearing weight on her right leg. OBJECTIVE: Multiple abrasions are noted on both forearms. Two lacerations are noted on the left elbow, approximately 2 centimeters in length. She has a sprain of the right knee, lower leg, and ankle. X-rays of the right knee, lower leg, and ankle were negative. Multiple views revealed no bony abnormality. There was slight soft tissue swelling over the lateral malleolus. TREATMENT: The lacerations on the left elbow were 1 inch long and 1/2 inch long. They were closed with interrupted 4-0 Prolene sutures after thorough cleansing. The abrasions were cleansed. She was given a tetanus toxoid booster, and a sterile dressing was applied. The patient is to be rechecked by her primary care physician in 48 hours. She left in good condition. DIAGNOSIS: Multiple abrasions, arms and legs. Laceration, left elbow. Sprain, right knee, lower leg, and ankle.

S50.811A, S50.812A, S80.811A, S80.812A, S51.012A, S93.401A, S83.91xA, V29.9XXA, Y92.9, Y99.9

This man cut his left thumbnail and thumb with a powered hand saw today, which flapped back the lateral aspect of the thumb. The thumb was cleansed, numbed, and one stitch put through the nail, fixing the flap in place. He is current on his tetanus immunizations. He will return to the office to have the stitch removed in six to eight days unless he experiences symptoms, in which case he is to call the office to be seen. DIAGNOSIS: Laceration, thumbnail and thumb, left.

S61.112A, W29.8xxA, Y92.9, Y99.9

SUBJECTIVE: This is a 28-year-old female who was handed a knife by her husband, blade first; and she accidentally punctured her left ring finger on the blade. OBJECTIVE: Patient has a superficial puncture wound over the lateral aspect of the left fourth finger. The area has been cleansed well, and a bandage was applied. ASSESSMENT: Puncture wound, left ring finger. (Initial encounter.) PLAN: Patient is to watch for any signs of infection and follow up with her primary care physician.

S61.235A, W26.0xxA, Y92.9, Y99.9

This 15-year-old male was struck on the left leg by a stick yesterday, which created a puncture wound in the skin of his leg. The patient presents today with swelling and localized redness around the wound. Physical exam reveals a healthy and cooperative 15-year-old male in no acute distress with a small puncture type wound approximately 5 millimeters in length on the anterior aspect of the left leg, just proximal to the knee. The wound is noted to have a small amount of induration, approximately 2 centimeters in diameter around the area with localized redness. There is no discomfort to motion of the knee. DIAGNOSIS: Puncture wound, left knee. (Initial encounter.) PLAN: The patient was instructed to use warm soaks to that knee several times each day and have it rechecked if it becomes worse. He will return or be seen sooner if the knee does not appear to improve. He was started on Keflex 500 milligrams four times daily.

S81.032A, W22.8xxA, Y92.9, Y99.9

SUBJECTIVE: This 22-year-old female was playing softball at a local baseball field yesterday when she twisted her ankle while running to second base. She states that she developed pain in the ankle subsequent to this injury and has been on crutches prior to her arrival in the ED this morning. She denies any previous significant injuries to the ankle. OBJECTIVE: Physical examination reveals a healthy, cooperative 22-year-old female in no acute distress. There is tenderness about the left ankle. There is no ecchymoses or swelling present. There is tenderness beneath both malleoli and anteriorly across the ankle. X-rays of the ankle show no evidence of fracture. PLAN: The patient was instructed to be on crutches for 7 days and maintain complete nonweightbearing and then begin partial weightbearing. If she is uncomfortable, she is to return to using crutches for several more days before attempting weightbearing. She is to elevate the leg and use ice, and she was advised to be reevaluated if she is not able to walk comfortably in 7 to 10 days. DIAGNOSIS: Sprain, left ankle.

S93.402A, Y93.64, Y92.320, Y99.8

A 45-year-old patient registers as an outpatient to undergo scheduled hemodialysis. The patient was born with just one kidney, which failed when she was 30 years old. She previously underwent a kidney transplant, which also failed. Currently, dialysis is her only option as she awaits the availability of another kidney for transplant. The hemodialysis takes three hours and is uneventful.

T86.12, Q60.0, Z76.82, Y83.0

A 39-year-old female patient undergoes a screening electrocardiogram (EKG) as an outpatient. She has a family history of cardiovascular disease. EKG results were negative. The nonspecific T-wave changes illustrated on the EKG were explained to the patient as probably due to anxiety and positional changes.

Z13.6, Z82.49

This 35-year-old states that her menstrual periods have been regular, and she had been taking birth control pills until January of this year. Since that time, she has been using other methods of birth control that are unsatisfactory to her. She and her husband also desire tubal ligation for prevention of further pregnancies. PHYSICAL EXAMINATION reveals a morbidly obese white female in no obvious distress; heart and lungs normal to auscultation; abdomen flat; on pressure, the cervix protrudes to the opening of the vaginal os; otherwise, the uterus was average size. Patient was taken to surgery and underwent laparoscopic bilateral tubal ligation. She was discharged in stable condition to be seen by Dr. Baker for follow-up care next week. DIAGNOSIS: Elective sterilization. Morbid obesity.

Z30.2, E66.01

This 31-year-old white female is admitted to the ambulatory surgery unit with chief complaint of multiparity. She states that she wants to undergo a sterilization procedure. She underwent laparoscopic tubal fulguration, bilateral. There are no familial diseases such as epilepsy, diabetes, bleeding tendency, tuberculosis, or heart attacks. She smokes a pack of cigarettes a day and takes no alcohol. She is married, but now separated. She has been in good health and has had no other problems. Her menses are every 28 days and last four days. No clots or pains. Her last period was January 1. She has two children living and well, ages 11 and 5. DIAGNOSIS: Encounter for sterilization procedure. Multiparity.History of tobacco use.

Z30.2, Z64.1, Z87.891