Practicode Set 1-200

OFFICE-ESTABLISHEDSEX: FEMALEAGE: 26DOS: 3/1/20XXOFFICE - ESTABLISHEDCHIEF COMPLAINT: Rash. Rash since December and spreading slowly. HPI: Rash/skin lesion. Reported by patient. Location: chest; abdomen. Quality: not itchy; not painful; increasing in size; had since last December. Severity: mild. Duration: has noted for >3 months. Context: no new detergents or skin products; no one else with similar rash; not scratching. Associated Symptoms: no fever; no cold symptoms; no nausea; no vomiting; no diarrhea; no urinary symptoms; no chills; no fatigue; no change in weight. PROBLEMS: • Pityriasis versicolor.ALLERGIES: Reviewed Allergies: PENICILLINS: Anaphylaxis. MEDICATIONS: Reviewed Medications.KETOCONAZOLE 2% TOPICAL CREAM. SEASONIQUE 0.15 MG TABSOCIAL HISTORY: Reviewed Social History: Smoking Status: smoker - current status unknown.PAST MEDICAL HISTORY: Reviewed Past Medical History.FAMILY HISTORY: Reviewed Family H

B36.0 Pityriasis versicolor 99212 Office/outpatient Established Sf Mdm

OPERATIVE REPORTSEX: FEMALEAGE: 83DATE OF OPERATION: 01/1/20XXSURGEON: Valentin KramerANESTHESIOLOGIST:ANESTHESIA: General endotracheal.PREOPERATIVE DIAGNOSIS: Lesion on Left Upper LungPOSTOPERATIVE DIAGNOSIS: Malignant Neoplasm, Upper Lobe of Left LungINDICATIONS: This patient who is a female was admitted to Medical Center Hospital with a hemorrhagic stroke. The etiology of the stroke was presumed to be embolus from atrial fibrillation and subsequent hemorrhage. At the time of her admission, a lesion in the left upper lobe was identified. On CT scan, there was an irregularly shaped nodule in the anterior portion of the left lung. On PET imaging, one small portion of this had avid FDG uptake. The remainder of the lesion had no uptake. It measured 1.6 cm by CT and there were no abnormal lymph nodes.PROCEDURE: Under satisfactory general anesthesia, the left chest: was entered through a limited posterolateral thoracotom

C34.12Malignant neoplasm of upper lobe, le 32505 LT Thoracotomy W/Therapeutic Wedge Rese 38746 Thorcom Thrc W/Medstnl And Regional

OPERATIVE REPORTSEX: FEMALEAGE: 43DATE: 01/01/20XXThis payer requires a LT or RT modifier.PREOPERATIVE DIAGNOSIS: Incomplete excision of melanoma, right calf.POSTOPERATIVE DIAGNOSIS: Incomplete excision of melanoma, right calf.OPERATION:1. Tumor excision, right calf .2. Rhomboid rotation flap, right calf .Surgeon: Christopher Thomas, M.D.1st Assistant: Jonathan Jones, M.D.Anesthesia:OPERATIVE INDICATIONS: Ms. Smith had an incompletely excised melanoma on her right calf. We have not reviewed the pathology. The margins were grossly positive. It was reportedly 0.4 mm and a Clark level II. This is yet to be confirmed. I do not know the ulceration status. She obtained a PET scan on X/X/20XX, which was clear. She has no adenopathy. Chest x-ray was clear December 15, 20XX. She presents today for a resection and closure. We are debating as to whether to do a flap or a skin graft.OPERATIVE PROCEDURE: The patient was taken to

C43.71 14301 RT

OPERATIVE REPORTSEX: FAGE: 73DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: 71-YEAR-OLD GRAVIDA IV, PARA 4-0-0-4 WITH HIGHLY SUSPECTED METASTATIC OVARIAN CANCER.PROCEDURES: EXPLORATORY LAPAROTOMY, SUBOPTIMAL DEBULKING OF OVARIAN CANCER, OMENTECTOMY, LEFT SALPINGO-OOPHORECTOMY WITH TUMOR.POSTOPERATIVE DIAGNOSIS: 73-YEAR-OLD GRAVIDA IV, PARA 4-0-0-4 WITH PRIMARY METASTATIC OVARIAN CANCER.SURGEONS: Hector Kramer, MDANESTHESIA: GENERAL, ENDOTRACHEAL.ESTIMATED BLOOD LOSS: 500 CC.IV FLUIDS: 4 LITERS OF LACTATED RINGER'S. AND 750 CC OF HESPAN.URINE OUTPUT: 100 CC CLEAR.SPECIMENS: OMENTAL CAKE, LEFT OVARY AND TUBES.COMPLICATIONS: NONE.CONDITION: STABLE.FINDINGS: There was 7 liters of clear ascites and large omental cake about 15 x 12 cm extending to diaphragm and right lobe of liver and numerous tumors adhered to bowel, bladder and peritoneum. The left ovary and tube infiltrated with tumor which was removed. A small uter

C56.2 C78.6 58952

OPERATIVE REPORTSEX: FemaleAGE: 71This payer requires RT and LT ModifiersDATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Left breast ductal carcinoma in situ.POSTOPERATIVE DIAGNOSIS: Left breast ductal carcinoma in situ.PROCEDURE PERFORMED:1. Partial mastectomy left breast, wire localized.2. Left axillary sentinel lymph node biopsy.ANESTHESIA: General with LMA.INDICATIONS: This is a female who was noted to have newly discovered micro calcifications on a mammogram performed in another state in March 20XX. She underwent a diagnostic mammogram in May 20XX which confirmed these findings. She underwent a stereotactic biopsy the next day, and this tissue that was removed showed an intraductal carcinoma in situ, high grade. She was noted to have a 3 cm area of concern on her mammogram. She was seen in my office and scheduled for a left axillary sentinel lymph node biopsy and a left breast partia

D05.12 Intraductal carcinoma in situ of lef 93011 LT Partial Mastectomy 38525 1 LT Bx/exc Lymph Node Open Deep Axillary 38900 1 LT Intraop Sentinel Lymph Id W/Dye Njx

OPERATIVE REPORTSEX: FEMALEAGE: 42ENCOUNTER: Office SurgeryDATE OF OPERATION: 01/1/20XXThis Payer requires LT or RT ModifiersSURGEON: Dr. Cohen AndrewsSKIN OTHER SYMPTOMS - four small growths/nevi. Removed today in office.HISTORY OF PRESENT ILLNESS: The patient comes in today to have four small skin lesions removed as they are either irritated by her bra or jewelry.CURRENT MEDICATIONS: Reviewed Medications.OXYCODONE HCI 10 MG TABPROVENTIL HFA 108 MCGVITAMIN D 5000 UNITS CAPSTests: • Blood pressure was high - 20XX.ALLERGIES:• Compazine TABS, reaction: heart races.• Penicillins, reaction: skin rashes/hives.• Reglan TABS, reaction: hallucinations/depression.• Squash, reaction: migraines.OBJECTIVE:Pre-Op Dx: four skin lesions.Post-Op Dx: same.Procedure: Excision of left shoulder nevus 0.5 cm. Excision of two left neck skin lesion each about 0.3 cm and excision of right shoulder skin lesion 0.4 cm.Anesthesia: 1%

D22.62 D22.61 D22.4 12031 LT 11400 59 LT 11104 11105 11105

RADIOLOGY REPORTValley HospitalTrisha SmithSEX: FAGE: 39DOS: 1/1/20XXPROCEDURE: PELVIC ULTRASOUND WITH TRANSABDOMINAL AND TRANSVAGINAL APPROACHCOMPARISON: None.INDICATIONS: Heavy menses.TECHNIQUE: Pelvic ultrasound using transabdominal and endovaginal technique.TRANSABDOMINAL FINDINGS:UTERUS: There is slight heterogeneity of the uterine echotexture. A focal abnormality is not definitely visualized. There is, however, mild thickening of the endometrium measuring up to 16 mm.OVARIES: Normal.CUL-DE-SAC: Negative.OTHER: Endovaginal imaging was performed for better evaluation of the uterus and ovaries.TRANSVAGINAL FINDINGS:UTERUS: The endometrium is slightly thickened and heterogeneous, measuring up to 16 mm. Immediately adjacent to the posterior aspect of the fundal endometrium is a hypoechoic 2.0 x 1.3 x 1.7 cm nodule, consistent with a submucous leiomyoma of uterus. No other focal areas of abnormal echogenicity are ide

D25.0 76830 26 76856 26

SEX: MALEAGE: 54DOS: 1/1/20XXPHYSICIAN: Jon Richard Jones, MDPREOPERATIVE DIAGNOSIS: Parotid neoplasm.POSTOPERATIVE DIAGNOSIS: Parotid neoplasm.OPERATIVE PROCEDURE: Right parotidectomy lateral to the facial nerve withfacial nerve dissection, and intraoperative cranial nerve monitoring of the facial nerve.SURGEON: Jon Richard Jones, MDPOSTOP CONDITION: Good.ANESTHESIA: General endotracheal.ESTIMATED BLOOD LOSS: 40 mL.COMPLICATIONS: None.FINDINGS: The patient had a palpable mass in the right parotid gland in front of the ear just inferior to the zygomatic arch. It was superficial to the facial nerve.INDICATIONS: This is a male, who has had a gradually enlarging right parotid gland tumor. He has also had an episode of parotiditis in the same gland. He has no facial paralysis. His health is otherwise good.DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, and placed on the table in supine position. Th

D49.0 Neoplasm of unspecified behavior of 42420 RT Exc Prtd Tum/prtd Glnd Tot Dsj&prsrv

OPERATIVE REPORTSEX: MALEAGE: 44DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: RIGHT PARIETAL BRAIN TUMOR.PROCEDURES: RESECTION OF RIGHT PARIETAL BRAIN MASS.POSTOPERATIVE DIAGNOSIS: RIGHT PARIETAL BRAIN TUMOR.SURGEON: Horacio Kramer, M.D.ANESTHESIA: GENERAL, ENDOTRACHEALINDICATIONS: This is a 44-year-old gentleman with a history of previous oligodendroglioma presents with severe weakness of his left upper and lower extremities and difficulty walking and almost monoplegia of the left upper extremity. Imaging study showed a very large mass about 8 cm with mass effect midline shift with faint enhancement consistent with malignant transformation. The patient was taken to the operating room after discussing the risks, benefits and possible complications of the procedure including worsening hemiplegia.PROCEDURE: The patient was brought to the operating room and placed in the supine position. After appropriate monitorin

D49.6 61510

OFFICE - ESTABLISHEDSEX: FemaleAGE: 57Date: 01/01/20XXCHIEF CONCERN: She is here for a four-month checkup.PROBLEM LIST1. Female patient with new onset atrial fibrillation with rapid ventricular response and spontaneous conversion (20XX).2. Hyperlipidemia.3. Hypothyroidism on Cytomel.4. Questionable history of hypertension.5. History of mild depression, now resolved, secondary to her husband's sudden death in mid-December 20XX.ALLERGIES: No known drug allergies.MEDICATIONS:Crestor 20 mg q.h.s.Flecainide 100 mg b.i.d.Cytomel 25 mcg q.d.Vitamin B Complex q.d.Vitamin B2 q.a.m.CoQ10 b.i.d.INTERVAL HISTORY:The patient is here for a four-month check. Overall, she feels quite well and continues exercising, walking three miles several days a week. Her weight is down nine pounds due to increased exercise and careful diet. She has had no palpitations.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 159 lbs. BP 132/80 in the left arm, p

E03.9Hypothyroidism, unspecified E78.5Hyperlipidemia, unspecified 99214 Office/outpatient Established Mod Md

MOUNTAIN HOSPITAL OPERATIVE REPORTSEX: FAGE: 59DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: DM type 2 related End-stage renal disease.POSTOPERATIVE DIAGNOSIS: DM type 2 related End-stage renal disease.PROCEDURE PERFORMED:1. Ultrasound-guided cannulation, right internal jugular vein.2. Tunneled Perm Cath placement, right internal jugular vein.3. Fluoroscopic-guided cannulation, superior vena cava.ANESTHESIA: Local MAC.SKIN PREP: ChloraPrep.DRAINS: None.DESCRIPTION OF PROCEDURE: The neck, shoulders and chest wall were prepped and draped. The patient was placed in Trendelenburg position and the right internal jugular vein was identified by ultrasound and was percutaneously accessed under ultrasound guidance. A guide wire was placed into the right atrium, confirmed by fluoroscopy. The insertion site was enlarged and a separate exit site was created. The catheter was tunneled from exit site

E11.22 N18.6 36558 RT 77001 26 76937 26

OPERATIVE REPORTSEX: FemaleAGE: 69DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Wet gangrene of the left medial foot along the first toe with cellulitis.POSTOPERATIVE DIAGNOSIS: Wet gangrene of the left medial footPROCEDURE PERFORMED:1. Left first toe ray amputation.2. Excisional debridement of the left foot wound with removal of necrotic skin, subcutaneous tissue, muscle and tendon.INDICATIONS: This is a pleasant elderly female with history of diabetes and hypertension who presented to the office with gangrene and foul odor involving the left foot. She was noted to have severe gangrene along the medial aspect of the metatarsophalangeal joint as well as pus draining from the wound. There was erythema overlying the dorsal aspect of the foot. The patient subsequently was admitted through the emergency room. She now presents for a left foot wound debridement with possible amputation of the

E11.52 I10 28810 TA 11043

OPERATIVE REPORTSEX: MaleAGE: 65DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Gangrene of the left great toePOSTOPERATIVE DIAGNOSIS: Gangrene of the left great toe.PROCEDURE PERFORMED: Left great toe partial amputation through the proximal interphalangeal joint with primary closure.ANESTHESIA: General endotracheal.INDICATION: This is a gentleman with Type 2 diabetes and other medical problems who developed gangrene of the left great tip toe. Arterial studies demonstrate a normal perfusion of the left foot. The gangrene has progressed slightly to involve the mid portion of the great toe. The patient presents today for a left great toe partial amputation. The risks, benefits, and alternatives of the procedure were discussed with the patient who understands and is in agreement to proceed.DESCRIPTION OF PROCEDURE: The patient was brought to the operating room and laid supine on the table. A

E11.52 Type 2 diabetes mellitus with diabet 28825 1 TA Amputation, Toe; IP Joint

OFFICE-ESTABLISHEDSEX: FEMALEAGE: 56DOS: 1/1/20XXCHIEF COMPLAINT: Hypertension, UTI, diabetes II, follow up.HPI: Diabetes. Reported by patient. Review finger sticks: fasting: 150. Duration: chronic. Control: improved since last visit. Compliance: compliant with medications; compliant with follow-up visits; compliant with diet; compliant with home glucose monitoring. Self-Care: monitoring glucose; seeing eye doctor regularly; checking feet regularly. Associated Symptoms: no weight gain; no weight loss; no dizziness; no sweats; no headaches; no confusion; no increased thirst; no increased appetite; no increased urination; no blurred vision; no numbness of feet; no calluses on feet; no kidney disease. Complications: no diabetic retinopathy; no diabetic neuropathy; no peripheral vascular disease; no diabetic nephropathy; no coronary artery disease; no diabetic ketoacidosis; hypertension; hyperlipidemia.UTI. Reported by p

E11.9 Type 2 diabetes mellitus without com E78.2 Mixed hyperlipidemia I10Essential (primary) hypertension N39.0Urinary tract infection, site not sp Z79.84Long term (current) use of oral hypo 99214Office/outpatient Established Mod Md

EMERGENCY DEPARTMENTSEX: FemaleAGE: 37DOS: 1/1/20XXTime Seen: 14:56 PM; initial patient contact.Arrived- By private vehicle. Historian- patient. No previous visits to this facility.HISTORY OF PRESENT ILLNESSChief complaint- ABDOMINAL PAIN. This started today and is still present. It was abrupt in onset and has been constant. It is described as pain, sharp and stabbing and it is described as located in the epigastric area and radiating (lower abdomen intermittently). At its maximum, severity described as severe. When seen in the E.D., severity described as severe. Modifying factors- Not worsened by anything. Not relieved by anything. She has had loose stools. This has occurred several times. No nausea, loss of appetite or vomiting.Similar symptoms previously: She has had similar symptoms twice previously. (With pancreatitis.).Recent medical care: The patient was seen recently and hospitalized. (PVH February and March)

E87.2 Acidosis R10.13Epigastric pain R00.0 Tachycardia, unspecified 99285 Emergency department visit for the e

OFFICE - ESTABLISHED SEX: FEMALEAGE: 69DOS: 1/1/20XXCHIEF COMPLAINT: Bilateral back pain, muscle pain. HPI: Back Pain: Reported by Patient: Locations: pain radiating to the buttocks; pain radiating to the legs. Quality: sharp. Severity: worsening; moderate (5-7). Duration: acute; chronic; muscle spasm. Context: prior back problems; used medications for back pain; had evaluations by back specialist. Alleviating Factors: rest; relived by changing position. Aggravating Factors: movement/positioning; twisting; flexing back; extending back. Associated Symptoms: no fever; no tingling; no incontinence; no shortness of breath; weak limbs; numbness of the legs/feet. Notes: RECENT LAB REVEALED LOW POTASSIUM.PROBLEMS: None Recorded. ALLERGIES: Allergies Not Reviewed (last reviewed 2/1/20XX). DARVON. IODINE. PENICILLINS. MEDICATIONS: Reviewed Medications: ADVAIR DISKUSATENOLOL 100 MG TABFENTANYLFLUTICASONEHYDROCODONE 10 MG TABLY

E87.6 Hypokalemia M51.36 Other intervertebral disc degenerative 99213 Office/outpatient Established Low Md

OFFICE - ESTABLISHED Sex: FAGE 71Date: 01/01/20XXCHIEF CONCERN: She is here for follow up of CPAP titration. PROBLEM LIST:1. A female with VVI pacemaker replacement (20XX), for chronic atrial fibrillation with intermittent high grade A-V block and uncontrolled ventricular rate.2. Recurrent heart failure associated with atrial fibrillation with rapid ventricular response.3. Recurrent deep venous thrombosis with a Greenfield vena cava filter placed, on maintenance Coumadin.4. Remote history of pulmonary embolism.5. Presyncopal episodes.6. Partial nephrectomy for nephrolithiasis.7. Sleep apnea, using CPAP daily as required.8. History of nonischemic cardiomyopathy, ejection fraction 45%, now 50-55%.ALLERGIES: No known drug allergies. MEDICATIONS: Warfarin 4 mg q.d. ADDigoxin 0.125 mg q.d.Metoprolol ER 50 mg q.d.CPAP and oxygen at nightDiltiazem 120 mg q.d.Multivitamin q.d.INTERVAL HISTORY: Since last office visit, the pa

G47.30 Sleep apnea, unspecified R41.3 Other amnesia Z79.01 Long term (current) use of anticoagu 99213 Office/outpatient Established Low Md

OPERATIVE REPORTSEX: MALEAGE: 39DATE: 01/1/20XXPREOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.POSTOPERATIVE DIAGNOSIS: Right carpal tunnel syndrome.OPERATION: Right carpal tunnel release,Surgeon: Christopher R. Kramer, M.D.1st Assistant:Anesthesia:Indications: This is a male with numbness and tingling in his right hand. He has positive electrodiagnostic studies of carpal tunnel syndrome. He has not responded to nonsurgical measures. He is being taken to the operating room for right carpal tunnel release. The risks and benefits were explained to him prior to proceeding.Procedure: The patient was given a regional anesthetic, and his right arm was prepped and draped sterilely below a tourniquet.A 2-cm longitudinal incision was made in the thenar crease and dissected through palmar fascia to the transverse carpal ligament. The distal end of the ligament was identified and incised from distal to proximal with a 6400

G56.01 Carpal tunnel syndrome, right upper 64721 1 RT Carpal Tunnel Surgery

SEX: MALEAGE: 75DOS: 1/1/20XXPHYSICIAN: Sidney Jones, MDPREOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome. OPERATIVE PROCEDURE: Left endoscopic carpal tunnel release. SURGEON: Sidney Jones, MDANESTHESIA: General. COMPLICATIONS: None. INDICATIONS: The patient a male who presented to clinic with left hand paresthesias in the median nerve distribution. Symptoms failed to improve with conservative management. Therefore, I recommended left endoscopic carpal tunnel release. The patient agreed, understanding the risks of nerve injury, tendon injury, persistent symptoms, recurrent symptoms, and need for further surgery. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room, where he was placed in a supine position. Left upper extremity was sterilely prepped and draped in the usual fashion. Esmarch bandage was used to exsanguinate the left upper extremi

G56.02 Carpal tunnel syndrome, left upper limb 29848 1 LT Ndsc Wrst Surg W/rls Transvrs Carpl

OPERATIVE REPORTSEX: FemaleAGE: 39This payer requires the use of Modifier 50 for bilateral proceduresDATE OF PROCEDURE: 1/1/20XXSURGEON: Levi Andrews, M.D.ANESTHESIOLOGIST: Joe D. Jones, M.D.PREOPERATIVE DIAGNOSES: Intermittent monocular exotropia, convergence excess.POSTOPERATIVE DIAGNOSES: Intermittent monocular exotropia, convergence excess.PROCEDURE: Bilateral lateral rectus recession with transposition of superior.ANESTHESIA: GeneralINDICATIONS FOR EYE SURGERY: Eye muscle imbalance.FINDINGS OF THE EYE SURGERY: Normal eye muscle.PROCEDURE IN DETAIL: The patient was brought to the operating room, placed under general anesthesia, and prepped and draped in standard fashion for eye surgery. A lid speculum was placed in the right eye. An inferotemporal conjunctival incision was made 10 mm from the limbus. The quadrant was spread with scissors. The lateral rectus muscle was hooked and cleaned with blunt dissection. 6-0

H50.331Intermittent monocular exotropia, ri H50.332Intermittent monocular exotropia, le H51.12 Convergence excess 67311 50 Strabismus Recession/rescj 1 Hrzntl 673201 Transposition Procedure Extraocular

EMERGENCY DEPARTMENTSEX: FEMALEAGE: 53DOS: 1/1/20XXAnne Jones, DOTime Seen: 8/1/20XX @ 14:40.History Source: Patient.Arrival Mode: Private vehicle.History Limitation: None.Additional Information: Chief Complaint from Nursing Triage Note: Reason for visit history.Reason For Visit History: Onset of eye burning, discoloration x 5 days.Patient presents with erythema and skin involvement that is suggestive of either contact dermatitis or possible poison oak. Patient denies obvious vision changes. No prior episodes.HISTORY OF PRESENT ILLNESS:The patient presents with red eye(s) and an eye problem. The onset was 5 days ago. The course/duration of symptoms is worsening. Type of Injury: None. The location where the incident occurred was at home. Location: Bilateral eye(s) eyelid. The character of symptoms is pain, redness and burning. The degree of symptoms is moderate. Exacerbating Factors: None. Relieving Factors: None. Pri

H57.13 Ocular pain, bilateral 99283 Emergency department visit for the e

AGE: 77SEX: MALEDATE OF OPERATION: 01/01/20XXPREOPERATIVE DIAGNOSIS: CHRONIC BLEB LEAK, RIGHT EYE.PROCEDURES: REVISION OF TRABECULECTOMY AND REPAIR OF BLEB LEAK RIGHT EYE.POSTOPERATIVE DIAGNOSIS: CHRONIC BLEB LEAK, RIGHT EYE.SURGEON:ANESTHESIA: MAC.COMPLICATIONS: NONE.PROCEDURE: The risks, benefits and alternatives of the surgery were explained in detail to the patient. Consent was signed for this procedure and placed in the patient's chart prior to performing the surgery.On the day of the surgery, the patient was properly identified and brought into the operating room. Intravenous anesthesia was given by the anesthesia team. Following the induction of local anesthesia and akinesia with a right-sided peribulbar and modified VanLint injection of a 50:50 mixture of 2% lidocaine and 0.5% bupivacaine, the patient was prepped and draped in the usual sterile fashion. Care was taken to drape the eyelashes from the operative

H59.89 Other postprocedural complications a Z98.83 Filtering (vitreous) bleb after glau 66250 RT Revision/Repair, Operative Wound, An

OPERATIVE REPORTSEX: MAGE: 4DOS; 1/1/20XXThis is a Commercial Payer (Follow Medicare rules for 65 and older) This payer requires RT and LT modifiersPHYSICIAN: J. Kramer, MDPREOPERATIVE DIAGNOSIS: Chronic Otitis Media.POSTOPERATIVE DIAGNOSIS: Chronic Otitis MediaOPERATIVE PROCEDURE: Right tympanostomy.SURGEON: J. Kramer, MDPOSTOP CONDITION: Good.ANESTHESIA: General by mask.ESTIMATED BLOOD LOSS: Negligible.COMPLICATIONS: None.OPERATIVE FINDINGS: Right tympanic membrane was retracted, thickened with copious thick, mucoid fluid in the middle ear. No attic retraction, pocket, or cholesteatoma was seen.INDICATIONS: This is a male, who underwent tympanostomies a year ago for recurrent otitis media. He did well, as long as the tubes are in place; however, recently, his right tube extruded, and since then he has had persistent otitis media despite chronic antibiotics.DESCRIPTION OF PROCEDURE: The patient was taken to the oper

H65.31 Chronic mucoid otitis media, right e 69436 RT Tympanostomy General Anesthesia

Pediatric Clinic Established Patient Sex: MAGE: 12DATE OF SERVICE: 1/1/20XXHISTORIAN: MotherVISIT TYPE: Office visitCHIEF COMPLAINT: Ear pain.HISTORY OF PRESENT ILLNESS: This 12 year old male presents with ear pain that started 1 day ago. The pain is located in the right ear. The problem was severe. Symptoms are associated with exposure to secondhand smoke. Symptoms are not associated with recent URI/cold and repeated Q-Tip use. Denies aggravating factors. Awoke from sleep at 4:00 a.m. with right ear pain.PHYSICAL EXAMINATION:GENERAL: No acute distress, nourishment type is overweight, well developed.VITAL SIGNS: Weight 209 pounds with BMI 28.34, 6'2 temperature 97.2HEENT: Eyes: No injection. Ears: Right, unremarkable to inspection. Canal normal in caliber, no excessive cerumen, no drainage. Tympanic membrane bulging and effusion-moderate. Left, unremarkable to inspection. Canal normal in caliber, no excessive cerumen

H66.001 E66.3 Z68.54 Z23 Z72.22 99213 25 90460 90460 90460 90461 90461 90660 90619 90715

OUTPATIENT PROCEDURECARDIOLOGYSEX: MALEAGE: 33Transthoracic Echocardiography ReportComplete 2D Study with M-Mode, Complete Spectral Doppler, and Color Doppler01/01/20XXMR#Account: Status: OutpatientLocation: Tape: Ht 65 in (165.1 cm)Wt 148 lb (63.7 kg)BSA 1.74 m squaredEcho Attending: Echo Technologist: Attending Ordering: SummaryLeft ventricle: Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. Tricuspid valve: There was mild tricuspid insufficiencyCOMPARISONS: No previous study is available for comparison.PROCEDURE: The procedure was performed in the outpatient area.. This was a routine study. The transthoracic approach was used. Complete 2D echocardiography study was performed with M-mode, complete spectral Doppler, and color Doppler. The heart rate was 77 b.p.m. at start. Systolic blood pressure was 120 mmHg at start. Diastol

I07.1 93306 26

OFFICE - ESTABLISHEDSEX: FemaleAGE: 67Date: 01/01/20XXCHIEF CONCERN: She is here for four-month checkup.PROBLEM LIST:1. Hypertension, adequately controlled on present medications.2. Abnormal EKG.3. Hyperlipidemia.ALLERGIES: Sulfa (nausea and vomiting), simvastatin (agitation).MEDICATIONSCardizem CD 240 mg q.d.Lisinopril 40 mg a.m. and 20 mg p.m.Lorazepam 1 mg b.i.d.Fenofibrate 160 mg h.s.Omega 3 fish oil q.d.Calcium 1000 mg q.d.Vitamin D3 400Move FreeTylenol Arthritis h.s.Metoprolol ER 50 mg q.d.INTERVAL HISTORY:Following complaints of increasing lower extremity edema, diltiazem was decreased and beta blocker was added. Overall, she feels quite well. Home blood pressures are now 120/80 to 138/89, pulse 69 to 80. She is having no significant side effects. Last month, she was treated as an outpatient for bronchitis, which has now completely resolved and she feels well.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 184 lbs, B

I10 Essential (primary) hypertension R00.0 Tachycardia, unspecified 99213 Office/outpatient Established Low Md

ESTABLISHED PATIENTSex: FAGE: 84Attending Physician:Primary Care Physician:Date: 01/01/20XXCHIEF CONCERN: She is here for three-month check and pacemaker interrogation.PROBLEM LIST1. Patient with chronic atrial fibrillation.2. S/P complete A-V node ablation for uncontrolled ventricular rate (20XX).3. VVI pacemaker replaced 2010.4. Nonischemic cardiomyopathy, ejection fraction 30%, improving to 50-55%.5. Hypertension.6. Low HDL. The patient declines all statins. She is using herbal medicines.7. Type 2 diabetes mellitus, diet-controlled.8. History of exertional shortness of breath, now mostly resolved.9. Nocturnal hypoxemia, treated with nocturnal oxygen, possible sleep apnea.10. S/P non-STEMI (20XX) secondary to diagonal branch occlusion; residual 80% mid left anterior descending stenosis, managed medically.ALLERGIES- ValiumStopped taking Coreg due to adverse affects.Coreg (causes lightheadedness and dizziness)MEDICAT

I10Essential (primary) hypertension I48.20Chronic atrial fibrillation, unspeci R42Dizziness and giddiness T44.7X5A Adverse effect of beta-adrenorecepto Z45.018 Encounter for adjustment and managem Z79.01 Long term (current) use of anticoagu 99214 25 Office/outpatient Established Mod Md 93288 26 Interrog Dev Eval Pm/ldls Pm Phys/qh

OFFICE - ESTABLISHEDSEX: MALEAGE: 63DOS: 1/1/20XXCHIEF COMPLAINT: Insomnia. Followup: Niddm controlled. Followup: Hypertension controlled. HPI: Diabetes. Reported by patient. Review finger sticks: post breakfast: 83; post dinner: ___ (left blank). Context: normal range of home blood sugars (in the low 100s). Seeing eye doctor regularly; checking feet regularly; not missing doses of medications. Associated Symptoms: no weight gain; no weight loss; no dizziness; no sweats; no headaches; no confusion; no increased thirst; no increased appetite; no increased urination; no blurred vision; no numbness of feet; no calluses on feet.Hypertension F/U. Reported by patient. Associated Symptoms: no dizziness; no lightheadedness; no chest pain; no shortness of breath; no palpitations; no edema; no calf pain with exertion. Lifestyle: regular exercise; limiting/avoiding salt. Medications: taking medications as directed; no side effe

I10N/SEssential (primary) hypertension E11.9Type 2 diabetes mellitus without com G47.00Insomnia, unspecified Z79.84 Long term (current) use of oral hypo 99214 Office/outpatient Established Mod Md

OPERATIVE REPORTSEX: FemaleAGE: 67This payer requires the RT or LT modifiers.DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: End-stage renal disease(Hypertension) and mechanical failure of (dialysis) AV graft left arm.POSTOPERATIVE DIAGNOSIS: Same.PROCEDURE PERFORMED:1. Brachiocephalic AV fistula creation, left upper arm for dialysis2. Ligation AV graft, left forearm.ANESTHESIA: Local MAC.SKIN PREP: ChloraPrep.DRAINS: None.INDICATIONS: Failed AV graft (dialysis), left forearm, without flow obstruction.DESCRIPTION OF PROCEDURE: The left arm was prepped and draped. A transverse incision was made over the cephalic vein in the antecubital fossa extending it medially opening the previous declot incision. The cephalic vein was dissected out and dissected proximally as well. A counter incision was made further up on the upper arm to further mobilize the cephalic vein. Local anesthetic was admini

I12.0 Hypertensive chronic kidney disease N18.6 End stage renal disease T82.590A Other mechanical complication of sur Z99.2 Dependence on renal dialysis 36818 LT Arven Anast Opn Upr Arm Cephalic Vei 376071 LT Lig/banding Angioaccess Arteriovenou

INPATIENT - INITIALCARDIOLOGYChest Pain Admission H&P *SEX: MaleAGE: 69Chief Complaint: Male patient with sustained substernal chest pain, now 6 hours.Refractory to NTG, Lovenox, Integrilin, and ASA. Troponin to 0.23, serial EKG with mild precordial changes, but no STEMI.Review of SystemsConstitutional: Negative.Ear/Nose/Mouth/Throat: Negative.Respiratory: Nonsmoker.Cardiovascular: Hypertension well-controlled on Rx. No known lipid abn. Nondiabetic.Gastrointestinal: Negative.Genitourinary: Negative.Hematology/Lymphatics: Negative.Endocrine: Negative.Immunologic: Negative,Musculoskeletal: Negative.Integumentary: Negative.Neurologic: Negative.Psychiatric: Negative. Depression Hx on Remeron.All other systems negative.Health StatusProblem list:All ProblemsDepression / ConfirmedGOUT / ConfirmedHYPERTENSION ConfirmedActive Problems (3)DepressionGOUTHYPERTENSIONResult type: Physician noteResult date: 01/01/20XXResult status

I21.4 I10 99223

INPATIENT VISIT - INITIALSEX: MaleAGE: 86Chest Pain Admission H&P * Hospital Initial VisitChief Complaint: Chest Pain86 YO with Hx hypertension, DM, COPD, with recurrent left chest anterior chest pain, spontaneously resolving with entry troponin 0.24. EKG with IVSD, no prior for comparison.Review of Systems:Constitutional: Negative.Eye: Negative.Ears/Nose/Mouth/Throat: Negative.Respiratory: Negative.Cardiovascular: Negative.Gastrointestinal: Negative.Genitourinary: Negative.Hematology/Lymphatics: Negative.Endocrine: Negative.Immunologic: Negative.Musculoskeletal: Negative.Integumentary: Negative.Neurologic: Negative.Psychiatric: Negative.All other systems are negative.Health StatusProblem List:All Problems:Angina / ConfirmedHealth StatusProblem List:All Problems:Chest pain / ConfirmedCOPD / / ConfirmedDM 1 (Diabetes mellitus type 1) / ConfirmedHTN - Hypertension / / ConfirmedTissue perfusion alteration / ConfirmedAct

I21.4 Non-ST elevation (NSTEMI) myocardial I10 Essential (primary) hypertension E10.9T ype 1 diabetes mellitus without com J44.9 Chronic obstructive pulmonary diseas 99221 Initial hospital inpatient or observ

STRESS ECHOCARDIOGRAMSex: MaleAGE: 75Date: 01/01/20XXINDICATION: Coronary atherosclerosis of Native Vessel.Medications: Plavix, atorvastatin.Medications withheld: On all medications.Entry vital signs. BP 128/82, pulse rate 80 and regular, oxygen saturation 93% on room air.PROCEDUREResting EKG shows normal sinus rhythm.Resting echo shows normal wall motion in all segments, no mitral regurgitation per color flow Doppler. The patient exercised on a modified Bruce protocol for 54 seconds into stage Ill.Test terminated due to target heart rate.FINDINGSPeak heart rate of 38 bpm which is 94% of maximum predicted heart rate.Blood pressure response was flat.Peak double product of 18,768 which represents a low cardiac workload.Peak EKG shows no ST segment changes.Oxygen saturation maintained.Exercise capacity is Functional class III at 3.9 METs.Peak exercise echo shows no development of segmental wall motion. There is increase

I25.10 Atherosclerotic heart disease of nat E78.5 Hyperlipidemia, unspecified i51.7 Cardiomegaly L53.9 Erythematous condition, unspecified Z79.02Long term (current) use of antithrom 99214 25 Office/outpatient Established Mod Md 93350 Echo Tthrc R-t 2d W/wo M-mode Comple 93325 Dop Echocard Color Flow Velocity Map

OFFICE - ESTABLISHEDSEX: MaleAGE: 68Date: 01/01/20XXCHIEF CONCERN: He is here for hospital follow-up.PROBLEM LIST1. Hospitalized (12/15/20XX) for chest pain with left heart catheter showing Atherosclerotic heart disease, treated with LAD stent and anticipating CABG in approximately three months.2. Hypercholesterolemia.3. Hypertension.4. History of depression.5. History of gout.ALLERGIES: Lisinopril causes ACE cough.MEDICATIONS:Nitroglycerin sublingual p.r.n.Metoprolol ER 50 mg q. am.Aspirin 325 mg q. am.Allopurinol 500 mg b.i.d.Plavix 75 mg q.d.Atorvastatin 80 mg q. hsMirtazapine 45 mg q. hsINTERVAL HISTORY:Patient is a male who presented to the hospital with chest pain approximately two weeks ago. Left heart catheter revealed atherosclerotic heart disease including an LAD that was amicable to a stent, which was felt to be the most likely culprit. This was stented and he was placed on Plavix. After further discussion

I25.10Atherosclerotic heart disease of nat Z95.5 Presence of coronary angioplasty imp Z79.02 Long term (current) use of antithrom 99215 Office/outpatient Established High M

PATIENT INFORMATIONEmployer Name: Retired Financial Class: Managed care. Cardiac Catheterization / Angiography Report Diagnostic Report Study Date: 01/01/20XX Height: 162.6 cm BSA: 1.75 m2 Weight: 67.1 kg Performing: ANESTHESIA: Conscious Sedation - Time: 45 mins Procedures performed: Left heart catheterization. Clinical Summary:History: Risk factors: Hypertension. Indication: Chest pain. Abnormal nuclear stress test. Poorly controlled hypertension, 6 mo. S/P left renal artery stent.Procedure: Left heart cath, LV gm coronary angio & bilateral renal angio, R external iliac angio. Allergies: Indomethacin, amlodipine. Labs, prior tests, procedures, and surgery:Serum creatinine (current admission) of 0.6 mg/dl. Hematocrit 40.8 %. White blood cell count (WBC) 20.9 th/ul. Platelet count of 445 th/ul. Serum sodium (Na) of 139 mEq/L. Serum potassium (K) of 3.7 mEq/L. Glucose of 134 mg/dl. Blood urea nitrogen of 19 mg/dl. Hem

I25.10N/SAtherosclerotic heart disease of nat I10Essential (primary) hypertension R07.9Chest pain, unspecified R94.39 Abnormal result of other cardiovascu Z95.820 Peripheral vascular angioplasty stat 362521N/SSlctv Cath 1Stord W/Wo Art Punct/Flu 934581N/SCath Plmt L Hrt & Arts W/Njx & Ang 991521N/SMod Sed Same Phys/qhp Initial 15 Min 991531N/SMod Sed Same Phys/Qhp Each Addl 15 M 991531N/SMod Sed Same Phys/Qhp Each Addl 15

PROGRESS NOTESEX: FAGE: 94Attending Physician:Primary Care Physician:Date: 01/01/2XXCHIEF COMPLAINT: She is here for echocardiogram results.PROBLEM LIST1. 94-year-old with pulmonary hypertension, most severe at 86 mmHg, now 45 mmHg on Letairis and Revatio. She remains oxygen dependent.2. Hospitalized (01/01/20XX) for anemia, transfused with 2 units of packed RBCs.3. Hospitalized (01/20XX) for pneumonia, pleural effusions requiring thoracentesis, and increased pulmonary hypertension.4. Dual chamber pacemaker upgrade from VVI to DDD (01/20XX).5. S/P community acquired pneumonia (01/20XX); resolved with treatment.6. Paroxysmal atrial flutter and atrial fibrillation with 2:1 A-V block.7. Sick sinus syndrome, S/P single chamber VVI pacemaker (01/01/XX).8. History of coronary artery disease, S/P right coronary stent (8+ years ago).9. Hypothyroidism, on replacement therapy.10. Hypertension; markedly labile and difficult to

I27.20 I10 Z95.0 Z79.01 Z99.81 99213

OFFICE - ESTABLISHEDSEX: MaleAGE: 58Date: 01/01/20XXCHIEF COMPLAINT: He is here for four-month follow-up.PROBLEM LIST1. A male that is S/P Carbomedics aortic valve replacement, St Jude mitral valve replacement, ascending and aortic arch replacement, pericardiectomy (20XX).2. Nonischemic cardiomyopathy, ejection fraction initially 25%, now 40-45%.3. History of severe pulmonary hypertension to 85 peak arterial pressure, now 47 mmHg on Revatio.4. Long-term history of atrial fibrillation with DC cardioversion twice.5. History of hypertension (19XX).6. History of significant obesity losing 100 lbs.7. Adult onset diabetes and insulin dependent (20XX).8. Remote history of smoking.9. Positive family history for premature coronary artery disease. Sister died at age 45 of MI.10. History of suspected central sleep apnea, presently untreated.11. Severe bilateral varicose veins with history of ankle ulceration S/P laser and chemi

I27.20N/SPulmonary hypertension, unspecified I42.9Cardiomyopathy, unspecified Z79.01Long term (current) use of anticoagu Z95.2N/SPresence of prosthetic heart valve 99214 Office/outpatient Established Mod Md

OFFICE - ESTABLISHEDSex: FemaleAGE: 79Date: 01/01/20XXCHIEF CONCERN: She is here for test results.PROBLEM LIST1. Patient with chronically occluded proximal left anterior descending coronary artery, with extensive right LAD collaterals, with preserved left ventricular systolic function.2. Idiopathic thrombocytopenic purpura, refractory to high-dose steroids requiring p.r.n. platelet transfusions.ALLERGIES: Tetanus and diphtheria toxoid (anaphylaxis).MEDICATIONS:Crestor 20 mg q.d.Triamterene/HCTZ 75/50 mg q.d.Metoprolol succinate 100 mg dailyNitroglycerin sublingual p.r.n.Zoloft 25 mg q.d.Nitroglycerine patch 0.4 mg hourly (on a.m., off p.m.)Multivitamin q.d.INTERVAL HISTORY: The patient is here for a one-month check and test results.Echocardiogram (12/27/20XX) shows:1. Ejection fraction of 60% with normal left ventricular function.2. Elevated left atrial pressure.3. Mild to moderate mitral regurgitation (Insufficiency

I34.0 Nonrheumatic mitral (valve) insuffic J44.9Chronic obstructive pulmonary disease Z86.73 Personal history of transient ischem 99214 Office/outpatient Established Mod Md

OFFICE PROCEDURESEX: FEMALEAGE: 95Transthoracic Echocardiography ReportComplete 2D Study with M-Mode, Complete Spectral Doppler, and Color Doppler01/01/20XXMR#Account: Status: OutpatientLocation: Tape: Ht 65 in (165.1 cm)Wt 160 lb (72.7 kg)BSA 1.8 m squaredReason for visit: Mitral Valve Echo Attending: Echo Technologist: Attending Ordering: SummaryLeft ventricle: Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. Doppler parameters were consistent with abnormal left ventricular relaxation (grade 1 diastolic dysfunction).Aortic valve: The valve was probably trileaflet. Leaflets exhibited moderate calcification. Mitral valve: There was mild mitral regurgitation. Left atrium: The atrium was mildly dilated. COMPARISONS: Comparison was made with the previous study of 01/01/20XX. Aortic regurgitation is now noted. Mitral regurgitation

I34.0Nonrheumatic mitral (valve) insuffic I35.1Nonrheumatic aortic (valve) insuffic 93306 1 Echo Tthrc R-t 2d W/wom-mode Compl S

OFFICE - ESTABLISHEDCARDIOLOGYPROBLEM LIST:1. Patient is a male with history of questionably significant cardiac valvular insufficiency.2. Borderline hyperlipidemia.3. Nonspecific EKG abnormality.ALLERGIES: No known drug allergies.MEDICATIONS:Ibuprofen p.r.n.Fish oil q.d.Vitamin C q.d.INTERVAL HISTORY: The patient presents today for stress echocardiogram that was quite limited due to leg fatigue after only 1 minute 32 seconds; however, there was no evidence of valvular insufficiency. His oxygen saturation was well-maintained. No evidence of ischemia. Test limited to very low cardiac workload. He reports 15 years and five years ago, he had minor carotid artery stenosis and has had some episodes of lightheadedness.PHYSICAL EXAMINATION:VITAL SIGNS: BP 146/90, pulse 95 and regular, oxygen saturation 97% on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue

I38 Endocarditis, valve unspecified E78.5 Hyperlipidemia, unspecified Z86.79 Personal history of other diseases o 99213 25 Office/outpatient Established Low Md 93351

PROGRESS NOTESex: FemaleAge: 61Consulting Physician:Referring Physician:Date: 01/01/20XXPROBLEM LIST1. 12 years S/P 2-vessel CABG.2. Hypertension.5. Hyperlipidemia.ALLERGIES: No known drug allergies.MEDICATIONSAspirin 81 mg q.d.Amlodipine 5 mg q.d.Metoprolol succinate 50 mg q.d.Simvastatin 20 mg q.d.Micardis HCT 80/25 mg q.d.Potassium Chloride ER 20 mcg Monday, Wednesday and FridayFurosemide 40 mg Monday, Wednesday and FridayNitrolingual pump spray 0.4 mg p.r.n.Calcium 1500 mg q.d.Vitamin D 1000 IU q.d.INTERVAL HISTORY: Clinical notes from the Cardiology Center indicate she had a cardiac catheterization, following an abnormal nuclear cardiac scan that showed preserved left ventricular systolic function with significant elevation of left ventricular filling pressures (pulmonary capillary wedge pressure of 21 mmHg and left ventricular end-diastolic pressure of 25 mmHg). She had proximal high-grade disease to the proxim

I42.5N/SOther restrictive cardiomyopathy G47.30Sleep apnea, unspecified E78.5Hyperlipidemia, unspecified I10N/SEssential (primary) hypertension

OPERATIVE REPORTCARDIOPULMONARYAGE: 56SEX: FemaleDATE OF SERVICE: 01/01/20XXREFERRING PHYSICIAN: MDFLUOROSCOPY TIME:10 minINDICATIONS: Atrioventricular block, second degreePROCDURES PERFORMED:1. Dual-chamber pacemaker implantation2. Axillary venogramOPERATOR: MDConscious Sedation - Intraservice Time: 45 mins.COMPLICATIONS: None.DESCRIPTION OF PROCEDURE: The patient entered the lab in a fasting state. She was prepped and draped in the usual sterile manner.Preparation: consent was obtained, and the risks of the procedure, benefits and alternatives were explained to patient. IV established. O2 administered. Placed on pulse oximeter and cardiac monitor. Suction was made available. Analgesia/sedation given. Medications: Fentanyl IV and Propofol IV administered. Patient status during sedation was attended constantly and was cooperative. Vitals were stable.Post-procedure: Recovery was uneventful. Returned to baseline. Sedat

I44.1 Atrioventricular block, second degre 332081 ns New/Rplcmt Prm Pm W/Transv Eltrd 99152 Mod Sed Same Phys/qhp Initial 15 Min 99153 Mod Sed Same Phys/Qhp Each Addl 15 M 99153 Mod Sed Same Phys/Qhp Each Addl 15 M

OFFICE - ESTABLISHEDSEX: FemaleAGE: 92Date: 01/01/20XXCHIEF COMPLAINT: She is here for four-month check.PROBLEM LIST1. Patient is a female who is S/P dual chamber pacemaker replacement for battery at elective replacement (01/20XX).2. S/P right ventricular lead revision for lead fracture and battery replacement (01/20XX).3. S/P dual chamber pacemaker implant (20XX) for complete heart block.4. History of paroxysmal supraventricular tachycardia and atrial fibrillation.5. History of hypertension.6. History of hypothyroidism — on replacement therapy following partial thyroidectomy.7. History of TIA manifested by transient dysphasia.8. S/P left central retinal artery occlusion (01/01/XX), presumed embolic.9. Mild and improving depression since death of her husband several months ago.ALLERGIES: Amiodarone (GI upset), Lipitor causes increased liver function tests.MEDICATIONS:Propafenone 150 mg b.i.d.Calcium 1500 mg plus D

I47.1 Supraventricular tachycardia I48.91N/SUnspecified atrial fibrillation I10N/SEssential (primary) hypertension Z79.01 Long term (current) use of anticoagu Z95.0 Presence of cardiac pacemaker 99214 Office/outpatient Established Mod Md 93000 Ecg Routine Ecg W/least 12 Lds W/i&r

PROGRESS NOTESex: FAGE: 91Attending Physician:Referring Physician:Date: 01/01/20XXCHIEF CONCERN: She is here for three-month check and pacer check.PROBLEM LIST1. A female with hospitalization (20XX) for recurrent ventricular tachycardia, associated dizziness and syncope, managed with amiodarone. Normal left heart cath.2. Severe ischemic cardiomyopathy, ejection fraction 15%.3. S/P DDD/AICD pacer (20XX) for sick sinus syndrome.4. S/P generator replacement for battery (20XX).5. S/P dual chamber AICD implant (20XX).6. Complete proximal dominant RCA occlusion, 60% mid-LAD stenosis, normal circumflex.7. Nonsustained ventricular tachycardia.8. Hypothyroidism, on replacement therapy.9. S/P MI (19XX).10. Osteoporosis.ALLERGIES: Altace, Lisinopril (hypotension, fatigue)MEDICATIONSAmiodarone 200 mg q.d.Coreg 6.25 mg t.i.d.Levoxyl 75 mcg q.d.Spironolactone 25 mg q.d.Calcium plus D 600 mg b.i.d.Plavix 75 mg q.d.Zinc 50 mg q.d.Vi

I47.2Ventricular tachycardia E03.9Hypothyroidism, unspecified R21Rash and other nonspecific skin erup Z45.02 Encounter for adjustment and managem Z79.02Long term (current) use of antithrom 99214 25Office/outpatient Established Mod Md 93289 Interrog Eval F2F 1/Dual/Mlt Leads I

OFFICE - ESTABLISHEDCARDIOLOGYSEX: MALEAGE: 77Date: 01/01/20XXPROBLEM LIST:1. Male with paroxysmal atrial fibrillation.2. Hypertension with recent suboptimal control.3. Hyperlipidemia.ALLERGIES: No known drug allergies.MEDICATIONS:Simvastatin 5 mg q.d. Fish oilDiltiazem 120 mg q.d. Vitamin DAspirin 162 mg q.d. CoQ10Pradaxa 150 mg q.d. KCl 20 mEq q.d.Multivitamins q.d.INTERVAL HISTORY:Followup stress echocardiogram (12/31/20XX) showed:1. No evidence of ischemia at a moderately high workload.2. No induced arrhythmia.Note: His baseline rhythm was low atrial, but he promptly converted to sinus rhythm. He is having no difficulties with his Pradaxa and no cardiorespiratory symptoms.PHYSICAL EXAMINATIONVITAL SIGNS: BP 106/72, pulse 65 and regular, oxygen saturation 95% on room air.CONSTITUTIONAL: He is healthy-appearing.HEENT: Eyes: Fundi show increased light reflex. No hemorrhages or exudates. No xanthelasma or exophthalmo

I48.0 Paroxysmal atrial fibrillation I10Essential (primary) hypertension E87.5 Hyperkalemia Z79.02Long term (current) use of antithrom Z79.82 Long term (current) use of aspirin 99214 Office/outpatient Established Mod Md

OFFICE - ESTABLISHEDCARDIOLOGYSEX: FEMALEAGE: 65Date: 01/01/20XXPROBLEM LIST:1. Female patient with paroxysmal atrial fibrillation, six months S/P atrial fibrillation ablation.2. Hypertension.3. She is seven years S/P gastric bypass surgery.4. Hepatitis C.5. Questionable TIA (01/20XX) manifest as a syncopal spell. No localizing neurologic symptoms.ALLERGIES: No known drug allergies.MEDICATIONS:Albuterol inhaler q.d.Omeprazole 20 mg t.i.d.KCl 10 mEq b.i.d. Gabapentin 800 mg t.i.d.Tramadol 50 mg t.i.d.Sotalol 160 mg b.i.d.Diovan HCTZ 320/12.5 mg 1/2 tab q.h.s. Trazodone 100 mg q.d. q.h.s. Multivitamins q.d.Calcium with vitamin D q.d.Fiber q.d.Valerian root q.d.Lasix 20 mg q.d.KCl 10 mEq q.d.INTERVAL HISTORY:Carotid Doppler (01/01/20XX) shows:1. 80-99% right ICA stenosis.2. 60-79% left ICA stenosis.Labs (01/01/20XX) show:1. Fasting lipids: Total cholesterol 115, triglycerides 54, HDL 65, LDL 44.2. TSH 1.6.Chemistry pane

I48.0Paroxysmal atrial fibrillation I34.0 Nonrheumatic mitral (valve) insuffic I65.21 Occlusion and stenosis of right caro I45.89 Other specified conduction disorders Z86.19 Personal history of other infectious Z86.73 Personal history of transient ischem Z98.890 Other specified postprocedural state 99214 25 Office/outpatient Established Mod Md 93350 Echo Tthrc R-t 2d W/wo M-mode Comple 93325 Dop Echocard Color Flow Velocity Map

HOLTER MONITORSEX: MaleAGE: 51Attending Physician:Referring Physician:Date: 01/01/20XXINDICATION: PalpitationsMEDICATIONS: Atenolol.PROCEDURE: The patient was monitored on a three-channel Holter monitor for a period of 24 hours.FINDINGS: Rhythm is sinus rhythm.The average heart rate is 73 b.p.m.The minimum heart rate is 65 b.p.m.The maximum heart rate is 123 b.p.m., which was sinus tachycardia at 1449 hours. No diary entry.Occasional PACs, rare PVCs. No pauses.Diary entry at 2202 hours of waking up with palpitations. Rhythm at that time was sinus rhythm at 66 b.p.m. No ectopy.Of note: Diary entry at 1244 hours of palpitations, but monitor had stopped after 24 hours.CONCLUSION1. Sinus rhythm with heart rates from 65 to 123 b.p.m., with Premature Ventricular Depolarization and no pauses.Robert JonesElectronically Signed by ROBERT JONES 1/1/20XX Case ID : OPD7113

I49.3 Ventricular premature depolarization 93224 1 Xtrnl Ecg & 48 Hr Record Scan Stor W

CARDIOPULMONARY REPORT:ADMISSION DATE: 01/01/20XX PT ROOM: W.2S04DISCHARGE DATE: DATE OF SERVICE: 01/01/20XXSURGEON PHYSICIAN: INDICATIONS: Sick sinus syndrome with sinus arrest. ANESTHESIA: Conscious Sedation - Time: 60 mins. administered by MD PROCEDURES PERFORMED: Dual-chamber pacemaker with A and B lead insertion, and an axillary venogram. DESCRIPTION OF PROCEDURE: After informed consent was obtained, and preoperative antibiotics given, the patient was brought to the procedure laboratory in a fasting state. The patient was prepped and draped in the usual sterile fashion. After local anesthesia with lidocaine and administration of conscious sedation by me, an incision was made in the infraclavicular area. Electrocautery was carried out to the level of the prepectoral fascia, and all bleeding was controlled with electrocautery. The pacemaker pocket was fashioned using electrocautery along the fascial planes. An axi

I49.5 I45.5 33208 99152 99153 99153 99153

INPATIENT VISIT - INITIALSEX: MaleAGE: 83Heart Failure Admission H&P *DATE OF SERVICE: 1/1/20XXAssociated Diagnoses: Left ventricular heart failure.Basic informationSource of history: Family member.Present at bedside: Family member.Referral source:History limitation: None.Chief Complaint83 YO S/P CABG 1986, and 5 Y S/P coronary angioplasty stent.2W SOB, weak. 1 D ago sustained anterior chest pain. To VA, troponin increased, sinus tachycardia, hypoxia, bilateral pleural effusions, RX ASA, Heparin, Digoxin. TX for managementReview of SystemsConstitutional: Fatigue. Decreased activity.Eye: Negative.Ears/Nose/Mouth/Throat: Chronic postnasal discharge.Respiratory: Cough.Cardiovascular: Tachycardia. Chest pain: Midsternal.Gastrointestinal: Negative.Genitourinary: Negative.Hematology/Lymphatics: Negative.Endocrine: Negative.Immunologic: Negative.Musculoskeletal: Negative.Integumentary: Negative.Neurologic: Prior TIAs.Psychi

I50.1Left ventricular failure, unspecifie Z95.5 Presence of coronary angioplasty imp Z95.1 Presence of aortocoronary bypass gra 99221

OFFICE - ESTABLISHEDAGE: 62Sex: MDate: 01/01/20XXCHIEF CONCERN: He is here for his Echo and AICD/VVI Defibrillator interrogation Results and a medication check.PROBLEM LIST1. Patient with nonischemic cardiomyopathy, ejection fraction initially 25%, now 55-60%.2. Chronic atrial fibrillation with difficulty controlling ventricular rate.3. History of persistent thrombus in the left atrial appendage; already on warfarin for atrial fibrillation.4. Three years S/P AICD/VVI pacemaker, S/P ICD shocks x2.ALLERGIES: No known drug allergies.MEDICATIONSWarfarin as directedMetoprolol tartrate 100 mg b.i.d.Coreg 37.5 mg b.i.d.Cartia XT 240 mg q.d.Viagra p.r.n.Digoxin 0.25 mg 1-1/2 tabs q.d.Levoxyl 25 mcg q.d.Mucinex p.r.n.INTERVAL HISTORYEchocardiogram done (12/15/20XX) shows:1. Ejection fraction of 55% with mildly dilated left atrium at 4.4 cm.2. Left ventricular hypertrophy that has been noted in a previous echocardiogram.AICD/V

I51.7 I42.0 I48.20 Z95.810 Z79.01 99214

AGE: 69SEX: FEMALEDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: SYMPTOMATIC RIGHT CAROTID STENOSIS.PROCEDURES: RIGHT EXTERNAL CAROTID ARTERY ENDARTERECTOMY LIGATION OF INTERNAL CAROTID ARTERY.POSTOPERATIVE DIAGNOSIS: SYMPTOMATIC RIGHT CAROTID STENOSIS, RIGHT ICA OCCLUSION.SURGEON: M.D.FIRST ASSISTANT:ANESTHESIA: GENERAL.ESTIMATED BLOOD LOSS: MINIMAL.COMPLICATIONS: NONE.INDICATION: The patient is a 69-year-old female who underwent mild stroke one month ago and at that time was diagnosed for a critical 80-99% right carotid stenosis and moderate left carotid stenosis based on carotid duplex and MRA of the bilateral neck vessels. She was recommended to undergo the surgery and after appropriate medical and cardiology evaluation, she was finally cleared for surgery.PROCEDURE: The patient was brought to the operating room and placed on OR table in supine position. General anesthesia was administrated. We encountered si

I63.231 Cerebral infarction due to unspecifi 35301 RT Teaec W/patch Grf Carotid Vertb Subc 37605 RT Ligation Internal/common Carotid Art

CARDIOLOGYSEX: FEMALEAGE: 52Transthoracic Echocardiography ReportLimited 2D Study with M-Mode, Limited Spectral Doppler, and Color Doppler01/01/20XXAccount: Status: InpatientLocation: Tape: Ht 68 in (172.7 cm)Wt 202.8 lb (92.2 kg)BSA 2.06 m squaredDiagnoses: - CEREBROVASC DISEASE NOSEcho Attending: Echo Technologist: Attending Ordering: SummaryProcedure information: This was a technically difficult study.Left ventricle: Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. Doppler parameters were consistent with abnormal left ventricular relaxation (grade 1 diastolic dysfunction).COMPARISONS: No previous study is available for comparison. HISTORY: PRIOR HISTORY: Peripheral vascular disease. Risk factors: hypertension, oral hypoglycemic-treated diabetes, alcohol abuse, and a history of current cigarette use (within the last month). P

I67.9 Cerebrovascular disease, unspecified 93308 26 Echo Transthorc R-t 2d W/wo M-mode R 93321 26 Dop Echocard Pulse Wave W/spectral F 93325 26 Dop Echocard Color Flow Velocity Map

OPERATIVE REPORTAGE: 40Sex: FSURGEON: Dr. Cohen AndrewsASSISTANT: Anne Jones, PA-CPREOPERATIVE DIAGNOSIS: Gangrene, right foot due to Peripheral Vascular Disease.POSTOPERATIVE DIAGNOSIS: Gangrene, right foot due to Peripheral Vascular Disease.PROCEDURE PERFORMED: Right below-knee amputation.ANESTHESIA: General.SKIN PREP: ChloraPrep.DRAINS: None.INDICATIONS: This patient has progressive gangrenous change, right foot. She has peripheral vascular disease and underwent intervention with angioplasty. Transcutaneous oxygen saturation study shows unlikely healing at the ankle but good healing at the below-knee area.DESCRIPTION OF PROCEDURE: The right lower extremity was prepped and draped. Flaps were outlined with a marking pen and incisions were made. A posterior flap was developed, dividing the gastrocnemius muscle at the level of the flap. The lesser saphenous vein was ligated and divided. The anterior compartment muscle

I73.9 27880 RT

OPERATIVE REPORTSEX: FemaleAGE: 36This payer requires RT and LT ModifiersDATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Recurrent left leg varicose veins.POSTOPERATIVE DIAGNOSIS: Same.PROCEDURE PERFORMED: Excision of recurrent varicose veins.INDICATIONS: Patient underwent ablation of the left GSV some time ago. She presents now with recurrent varices over the left lateral leg. I have recommended excision of these recurrent veins as the saphenous vein remains closed and the lesser saphenous vein competent. I have agreed to provide sclerosis of telangiectasia at no additional cost to the patient. Risks and benefits were explained and include bleeding, infection, pigmentation and further recurrence. She has signed appropriate consents.ANESTHESIA: Local.DESCRIPTION OF PROCEDURE: Patient was made comfortable on the procedure table. The left lateral leg was prepped with Betadine. A total of 10

I82.92 I78.1 37765 LT

Post Op and followup visit - S/P aortic valve surgery by Dr. JonesSex: FemaleAge: 63Date: 01/01/20XXPROBLEM LIST1. Female with five weeks S/P St. Jude aortic valve replacement for severe symptomatic aortic valve stenosis.2. Medical Center visit 10 days ago for chest wall pain associated with shortness of breath, sinus tachycardia and fluid retention, managed with diuretics.ALLERGIESMEDICATIONSTylenol #3 bid.Coumadin ADLasix 40 mg q.d.KCl 20 mEq q.d.Metoprolol succinate 75 mg b.i.d.INTERVAL HISTORY: The patient has had no further difficulties with her sternal wound. She has some right anterior chest tenderness which is improving. chest pain has resolved. Shortness of breath has improved. She is ambulating in her back yard. Leg swelling is still evident but resolving. She has minimal residual cough. No sputum.PHYSICAL EXAMINATIONVITAL SIGNS: Weight 191 lbs (down 4 lbs). BP 102/64 in the left arm (lg. cuff), pulse is 87

I97.89 Other postprocedural complications a R60.0 Localized edema Z95.2 Presence of prosthetic heart valve Z79.01Long term (current) use of anticoagu 99024 Postop Follow Up Visit Related To Or

OFFICE-ESTABLISHEDSEX: FEMALEAGE: 26DOS: 1/1/20XXCHIEF COMPLAINT: Established patient, sore throat. Patient is being seen for a sore throat. Patient states that her throat started hurting on 8/1/20XX. Patient has nasal drainage down the back of her throat and her nose.HPI: 26 y/o female c/o sore throat x 3 days. + bilateral ear pain + runny nose + post nasal drainage. Denies cough, fever, chills. Works at a daycare.PROBLEMS: Reviewed Problems.• Tonsillitis.ALLERGIES: Reviewed Allergies. GANTRISIN - as a child. NKDA.MEDICATIONS: Reviewed Medications. AUGMENTIN 875 MG TABVACCINES: Reviewed Vaccines. Influenza, seasonal - 20XXSOCIAL HISTORY: Reviewed Social History. Family Practice: Alcohol Intake: none. Non-Smoker. Smoking Status: never smoker. PAST MEDICAL HISTORY: Reviewed Past Medical History: Chicken Pox: Y - childhood. Ear or Hearing Problems: Y. Eye or Vision Problems: Y. Other: Y - HTN of pregnancy. Sinusitis:

J03.90 Acute tonsillitis, unspecified 99213 Office/outpatient Established Low Md 87880 QWInfectious agent antigen detection b

EMERGENCY DEPARTMENTSEX: FEMALEAGE: 70DOS: 1/1/20XXTime Seen: 06:21; initial patient contact. Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESSChief complaint- cough, coughing up blood. This started yesterday and is still present. It has been intermittent. The dyspnea is described as mild and is worsened by cough and is improved by rest. She has had a cough. The patient has had sputum production (occasional). No fever or chest pain. (Pt reports cough for the past 3 days. Seeing occasional streaks of blood and small dark clots with cough since yesterday. Reports having had this in October as well. Had f/u with Dr. Jones at that time and told she had scar tissue in her R lung base. Still eating and drinking well. Denies fevers.). Similar symptoms previously: She has had similar symptoms once previously. Recent medical care: Not recently seen/assessed. REVIEW OF SYSTEMSThe patient has not had w

J20.8N/SAcute bronchitis due to other specif R04.2Hemoptysis 99284 25 Emergency department visit for the e 93010 Electrocardiogram Report

EMERGENCY DEPARTMENTSEX: FemaleAGE: 27DOS: 1/1/20XXCHIEF COMPLAINT: Cough.HISTORY OF PRESENT ILLNESS: This is a female who states she has had a cough for 10 years, no fevers, chills. She has had some slight nasal discharge, no real sore throat. She has intermittent right ear pain. No shortness of breath. No nausea, vomiting, diarrhea, or abdominal pain.PAST MEDICAL HISTORY: She states is basically unremarkable. She has been on albuterol, Vicodin, ibuprofen, but not recently. She is currently on ibuprofen p.r.n.ALLERGIES: None.SOCIAL HISTORY: The patient is a nonsmoker, nondrinker.REVIEW OF SYSTEMS: Only positive as above.PHYSICAL EXAM: VITAL SIGNS: Temperature 99; pulse 102; respiratory rate is 18; with a pulse ox of 98%, which is good for her on room air; blood pressure 164/102, recheck blood pressure was done, the patient's blood pressure will be rechecked; weight 116 kilos. GENERAL: The patient is alert and orient

J40Bronchitis, not specified as acute H92.01N/SOtalgia, right ear H61.21N/SImpacted cerumen, right ear I10Essential (primary) hypertension 99283 25 Emergency department visit for the e 69209 RT Removal Impacted Cerumen Irrigation

EMERGENCY DEPARTMENTAGE: 89Sex: FDOS: 01/01/20XXTime Seen: 15:09Arrived- By private vehicle. Historian- patient and family. Note: Previous visits to this facility for similar complaints.HISTORY OF PRESENT ILLNESSChief complaint- DYSPNEA and HISTORY OF ASTHMA and WHEEZING. This started several days ago and is still present and now worse. It is not improving. It was gradual in onset and has been constant. The dyspnea is described as moderate. The dyspnea is worsened by walking, exertion, being in a supine position and cough, is improved by rest, is improved with oxygen and is improved with sitting upright. She has had a subjective low grade fever. The patient has had a moderate cough, wheezing, dyspnea on exertion and dizziness. No chest pain or discomfort, calf pain or foot swelling.Similar symptoms previously: She has had similar symptoms several times previously.Recent medical care: The patient was seen recently at

J44.9 E87.1 R93.89 M85.80 Z87.440 Z87.09 99285 93010 93042 59

MEDICAL RECORD OFFICE - ESTABLISHEDSEX: FEMALEAGE: 66DOS: 1/1/20XXCHIEF COMPLAINT: 3 mo. f/u, med refillHPI: COPD. Reported by patient. Onset/Timing: was in A/A 2 weeks ago and sore - has apt to see Dr. Bob Kramer tomorrow. Severity: moderate; using her oxygen at night. Quality: having some shortness of breath with activity. Associated Symptoms: no fever; arouses from sleep; dyspnea; dyspnea during exertion; decrease in exercise capacity; fatigue; cough. Note: Taking her meds well; keeps her appts with Dr. Bob Kramer and she is now going to see Dr. Amy Andrews for biopsy/test of thyroid nodule next week. Was seen in ER after her wreck - 1 month ago; x-rays of chest and CT of head and neck and all OK except nodule of thyroid. Needs refill of her pain meds for her arthritis. Needs her INR checked. Depression. Reported by Patient. Severity: denies suicidal ideations. Associated Symptoms: denies homicidal ideations; no v

J44.9Chronic obstructive pulmonary diseas G47.00N/SInsomnia, unspecified F32.ADepression, unspecified M19.90N/SUnspecified osteoarthritis, unspecif Z79.01 Long term (current) use of anticoagu 99214 Office/outpatient Established Mod Md

EMERGENCY DEPARTMENTSEX: MaleAGE: 49DOS: 1/1/20XXArrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS:Chief Complaint: DENTAL PAIN. This started several days ago and is still present and worsening. It was gradual in onset and has been constant. Pain described as moderate. He has had moderate toothache involving a single tooth ( left upper molar). The patient has had moderate swelling of the left face. He has had moderate left-sided facial pain. No swollen jaw or jaw pain. Similar symptoms previously: He has had similar symptoms several times previously. Diagnosed as dental caries and abscess. Recent medical care: The patient was seen recently at another facility in a clinic. (scheduled for extensive dental work at home in NYC but he is on the road and needs some abx and pain meds until he gets back home.). REVIEW OF SYSTEMS:No fever, eye discomfort, cough, difficulty breathing or chest pain. No

K04.7 Periapical abscess without sinus K02.9 Dental caries, unspecified 99283 Emergency department visit for the e

OPERATIVE NOTESEX: MaleAGE: 29DOS: 1/1/20XXPHYSICIAN:PREOPERATIVE DIAGNOSIS: Left inguinal hernia.POSTOPERATIVE DIAGNOSIS: Incarcerated left inguinal hernia (indirect).OPERATIVE PROCEDURE: Repair of incarcerated left inguinal hernia with mesh (PHSL).SURGEON:ASSISTANT: NoANESTHESIA: General, local.COMPLICATIONS: None.FINDINGS: He had a very large, indirect inguinal hernia. There was some omental fat, which was up into this hernia sac.INDICATIONS: The patient is a male who has had problems with a left inguinal bulge. He now presents for repair of an obvious left inguinal hernia.DESCRIPTION OF PROCEDURE: After informed consent was obtained and after marking the area, the patient was brought back to the operating room placed on the operating table in supine fashion. After adequate monitors were placed, the patient was placed under general anesthesia. The left groin was prepped with Hibiclens soap and sterilely draped. A

K40.30 49507 LT

OPERATIVE REPORTSEX: MaleAGE: 27This payer requires RT and LT modifiersDATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Left inguinal hernia.POSTOPERATIVE DIAGNOSIS: Indirect left inguinal hernia.PROCEDURE PERFORMED: Left inguinal hernia repair with mesh (PerFix plug and patch).ANESTHESIA: General.SKIN PREP: Betadine.DRAINS: None.INDICATIONS: Left inguinal hernia.FINDINGS: Indirect left inguinal hernia.DESCRIPTION OF PROCEDURE: The abdomen and groin were prepped and draped. Marcaine 0.25% with epinephrine was injected for postop pain relief. A left suprainguinal incision was made and carried down to the external oblique which was injected and opened in the direction of its fibers. Cord structures were encircled with a Penrose drain and the hernia sac was dissected away up into the internal ring where it was suture ligated with a pursestring of 2-0 Prolene. Redundant sac was excised. A larg

K40.90 49505 LT

OPERATIVE NOTEAGE: 30SEX: MaleDOS: 1/1/20XXPHYSICIAN: MDPREOPERATIVE DIAGNOSIS: Symptomatic right inguinal hernia.POSTOPERATIVE DIAGNOSIS: Right inguinal hernia.OPERATIVE PROCEDURE: Open right inguinal hernia repair with mesh (PHSL).SURGEON: MDANESTHESIA: General and local.COMPLICATIONS: None.FINDINGS: He had a medium-sized indirect inguinal hernia sac.INDICATIONS: The patient is a male, who has had a right inguinal bulge. This is tender and getting larger. He now presents for repair of this right inguinal hernia.DESCRIPTION: After informed consent was obtained, the patient was brought back to the operating room and placed on operating table in supine fashion. After adequate monitors were placed, the patient underwent general anesthesia. The right groin was prepped with Hibiclens soap and sterilely draped. A time out was performed, confirming the patient and the procedure. Local anesthetic was infiltrated into the sk

K40.90 49505 RT

OPERATIVE REPORTSEX: MaleAGE: 74This payer requires the Rt and Lt ModifiersDATE OF OPERATION: 01/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Right inguinal hernia, recurrent.POSTOPERATIVE DIAGNOSIS: Direct recurrent right inguinal hernia without obstruction.PROCEDURE PERFORMED: Direct recurrent right inguinal hernia repair with mesh (Prolene Hernia System).ANESTHESIA: General.SKIN PREP: Betadine.DRAINS: None.INDICATIONS: This patient previously underwent right inguinal hernia repair about 15-20 years ago and it has recently recurred.FINDINGS: Direct right inguinal hernia no obstruction. No previous mesh was encountered. Cutaneous scar was very difficult to identify.DESCRIPTION OF PROCEDURE: The abdomen and groin were prepped and draped. Marcaine 0.25% with epinephrine was injected for postop pain relief and a right suprainguinal incision was made and carried down to the external oblique which was injected

K40.91 Unilateral inguinal hernia, without 49520 RT Rpr Recrt Inguinal Hernia Any Age Re

OPERATIVE NOTEAGE: 52SEX: FemaleDOS: 1/1/20XXPHYSICIAN: MDPREOPERATIVE DIAGNOSES:1. Biliary colic.2. Symptomatic incisional hernia.POSTOPERATIVE DIAGNOSES:1. Biliary colic.2. Symptomatic incisional hernia.OPERATIVE PROCEDURE:1. Laparoscopic cholecystectomy.2. Repair of incarcerated incisional hernia (mesh = Ventralex 6.4 cm).SURGEON: MDASSISTANT:ANESTHESIA: General and local.COMPLICATIONS: None.FINDINGS: Gallbladder grossly appeared normal and came out easily. She did have an incisional hernia from a prior laparoscopic Nissen fundoplication. This defect was 2 cm by about 3 cm transversely. There was obvious incarcerated fatty tissue.INDICATIONS: The patient is a female who came in with an incisional hernia. She had further workup, which demonstrated biliary colic. She now presents for cholecystectomy and repair of incisional hernia.DESCRIPTION OF PROCEDURE: After informed consent was obtained and after marking the ar

K43.0Incisional hernia with obstruction, K80.50Calculus of bile duct without cholan 495611 59 475621Laparoscopy Surg Cholecystectomy 49568

SEX: FEMALEDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: PARACOLOSTOMY HERNIA.PROCEDURES: EXPLORATORY LAPAROTOMY, LYSIS OF ADHESIONS AND REPAIR PARACOLOSTOMY HERNIA WITH MESH.POSTOPERATIVE DIAGNOSIS: PARACOLOSTOMY HERNIA.SURGEON:ANESTHESIA: GENERAL, ENDOTRACHEAL.ANESTHESIOLOGIST:ESTIMATE BLOOD LOSS: APPROXIMATELY 50 ML.IV FLUIDS: 1200 ML CRYSTALLOID.URINE OUTPUT: 250 ML.COMPLICATIONS: NONE.FINDINGS: Paracolostomy hernia containing multiple small bowel loops. Multiple adhesions of the small bowel.PROCEDURE: The patient was taken to the operating room and laid down supine on the OR table. General anesthesia was initiated by way of endotracheal intubation. The area over the abdomen was scrubbed, prepped and draped in the usual sterile surgical fashion.The previous scar mark was then used to make an incision over midline abdomen. The incision was carried down through the subcutaneous tissue using electrocautery whil

K43.5 49560 49568

OPERATIVE REPORTSEX: MaleAGE: 55DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Severe proctalgia with hemorrhoids and probable anal fissure.POSTOPERATIVE DIAGNOSES:1. Posterior acute anal fissure.2. First Degree Internal hemorrhoids.PROCEDURES PERFORMED:1. Proctoscopy.2. Posterior anal fissurectomy and repair.3. Right lateral internal sphincterotomy.4. Internal hemorrhoid banding x 1.ANESTHESIA: Spinal.SKIN PREP: Betadine.DRAINS: None.INDICATIONS: This patient is suffering from severe proctalgia for two months with severe anal sphincter spasms, some possible hemorrhoid prolapse by his own description and clinically consistent with an anal fissure.FINDINGS: A deep posterior anal fissure was present in the midline. Internal hemorrhoids were prominent at the 9 o'clock position and 2 o'clock position (in lithotomy). Proctoscopy to 20cm was otherwise negative.DESCRIPTION OF PROCEDURE: The pat

K60.0Acute anal fissure K64.0First degree hemorrhoids 46200 1 Fissurectomy Incl Sphincterotomy Whe 46221 1 Hemorrhoidectomy Internal Rubber Ban

Age: 68Sex: MaleDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: PROLAPSE RECTUM.PROCEDURES: REDUCTION OF PROLAPSED RECTUM UNDER ANESTHESIA.POSTOPERATIVE DIAGNOSIS: PROLAPSE RECTUM.SURGEON: M.D.ANESTHESIA: GENERAL VIA FACE MASK.ANESTHESIOLOGIST: RUNG-TAN AndrewsESTIMATE BLOOD LOSS: NIL.DRAINS: NONE.IV FLUIDS: LACTATED RINGER'SCOMPLICATIONS: NONE.INDICATIONS: This is a male with history of constipation who presented to the ED with prolapse rectum that was not reducible by self.PROCEDURE: The patient was brought into the operating room and laid supine on the operating table. After anesthesia was induced, the patient was placed in the lithotomy position. A rectal exam was carried out digitally, and the anal sphincter was noted to be lax. The prolapsed rectum was noted to be viable with no ulceration or ischemia, it was easily reduced back into the pelvis. A small Vaseline tampon was placed in the anal canal and the bu

K62.3 Rectal prolapse 45900 1 Reduction, Procidentia (Sep Proc) Un

OPERATIVE NOTEAge: 55Sex: FDOS: 1/1/20XXPHYSICIAN: MDOPERATIVE PROCEDURE: Colonoscopy and 1st degree internal hemorrhoids and External Hemorrhoids.SURGEON: MDANESTHESIA: Conscious Sedation: 33 mins.INDICATIONS: Mrs. Smith is a female, who in April 20XX underwent colonoscopy and was found to have an obstructing cancer at 40 cm. She underwent partial colectomy and biopsy of a liver lesion that was metastatic. She subsequently underwent resection of two metastatic liver nodules by Dr. Benjamin Button. She is doing well but has recently developed some constipation is being seen for follow-up colonoscopy. Her examination shows internal first degree and external hemorrhoids (skin tags). She has an anastomosis at 25 cm that is well healed without excrescences. The colon shows a submucosal lipoma at 60 cm and in the cecum just adjacent to the ileocecal valve, she has a 1-cm sessile polyp that was removed with a snare polypec

K63.5 K64.0 K64.4 D17.79 K59.00 Z85.038 Z85.05 Z90.49 Z98.0 45385 99152 99153

EMERGENCY DEPARTMENTSex: MAGE: 74DOS: 1/1/20XXCHIEF COMPLAINT: Vomiting blood.HISTORY OF PRESENT ILLNESS: This is a male who was fine until about 4 p.m. today when he started getting nauseated. He began having some sweats, also felt cold and slightly dizzy. About 6:30 he vomited blood and it was a combination of red blood and dark blood. This occurred 3 times. The patient's family then called the ambulance. He has not vomited since. The patient denies any chest pain, syncope, presyncope, or shortness of breath. Denies any previous history of vomiting blood or any bleeding problems. Denies any history of ulcer disease or other problems with his stomach. Denies any abdominal pain.PAST HISTORY: Significant for (1) Mechanical aortic valve 10 years ago and has been on Coumadin ever since. He says his pro-times have been good at the Clinic. (2) History of primary biliary cirrhosis followed at Stanford which apparently has

K74.3 Primary biliary cirrhosis K92.2 Gastrointestinal hemorrhage, unspeci

OPERATION REPORTAge: 33SEX: MALEDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: ACUTE CHOLECYSTITIS STATUS POST CHOLECYSTOSTOMY TUBE.PROCEDURES: EXPLORATORY LAPAROSCOPY AND OPEN PARTIAL CHOLECYSTECTOMY WITH INTRAOPERATIVE CHOLANGIOGRAM.POSTOPERATIVE DIAGNOSIS: ACUTE CHOLECYSTITIS STATUS POST CHOLECYSTOSTOMY TUBE CONTAINED PERFORATED CHOLECYSTITIS.SURGEON: M.D.ANESTHESIA: GENERAL ENDOTRACHEAL TUBE.ESTIMATED BLOOD LOSS: ABOUT 100 CC.IV FLUIDS: 3 LITERS.SPECIMENS: GALLSTONES AND GALLBLADDER.COMPLICATIONS: NONE.CONDITION: STABLE.COUNTS: THE SPONGE, NEEDLE AND INSTRUMENT COUNTS WERE CORRECT AT THE END OF THE CASE.INDICATIONS: This is a male who has a history of acute cholecystitis that as treated about six weeks ago with percutaneous cholecystostomy tube. After a period of antibiotics and normalization of his white count, the patient was seen in our surgical clinic and scheduled for an elective cholecystectomy.PROCEDUR

K80.00 K82.2 Z53.31 Z97.8 47605

OPERATIVE REPORTSEX: FemaleAGE: 69DATE OF OPERATION: 01/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Cholelithiasis and chronic cholecystitis.POSTOPERATIVE DIAGNOSIS: Cholelithiasis and chronic cholecystitis.PROCEDURE PERFORMED: Laparoscopic cholecystectomy with operative cholangiography.ANESTHESIA: General.SKIN PREP: Betadine.DRAINS: None.INDICATIONS: Right-sided abdominal pain with documented cholelithiasis by ultrasound.FINDINGS: The gallbladder contained multiple tiny stones. Operative cholangiography showed good flow of dye into the duodenum but there were some small lucencies in the distal duct, possibly representing tiny stones. The biliary tree was not dilated. The gallbladder was think-walled and fragile. There were multiple adhesions to the liver with violin string adhesions on the surface of the liver and there were multiple adhesions in the lower abdomen from previous surgery.DESCRIPTION OF PRO

K80.10 Calculus of gallbladder with chronic 47563 1 Laps Surg Cholecystectomy W/cholangi 74300 1 Cholangiography&/pancreatography Ntr

OPERATIVE REPORTSEX: FemaleAGE: 33DATE OF OPERATION: 01/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS:1. Cholelithiasis.2. Chronic cholecystitis.POSTOPERATIVE DIAGNOSIS: Same.PROCEDURE PERFORMED: Laparoscopic cholecystectomy with operative cholangiography.ANESTHESIA: General.SKIN PREP: ChloraPrep.DRAINS: None.INDICATIONS: This patient has documented cholelithiasis with intermittent right upper quadrant and epigastric abdominal pain.FINDINGS: The gallbladder contained multiple small stones. The cystic duct was fairly long. Operative cholangiography showed good flow of dye into the duodenum with no evidence of stones or obstruction.DESCRIPTION OF PROCEDURE: The abdomen was prepped and draped. A small right subcostal incision was made through which a nonbladed 5-mm Optiview port was placed under direct vision. The abdomen was insufflated and contents briefly inspected. The patient then had a 5-mm umbilical port

K80.10 Calculus of gallbladder with chronic 47563 Laps Surg Cholecystectomy W/cholangi

OPERATIVE REPORTSEX: MaleAGE: 22DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Pilonidal cyst and sinus with abscessPOSTOPERATIVE DIAGNOSIS: Pilonidal cyst and sinus with abscessPROCEDURE PERFORMED: Excision of complicated pilonidal cyst and sinus abscess with marsupialization of wound.ANESTHESIA: General.SKIN PREP: Betadine.DRAINS: None.DESCRIPTION OF PROCEDURE: The patient was placed prone in a semi-jackknife position. Buttocks were taped apart. The patient was prepped. An elliptical incision was made around the pilonidal abscess opening and around a secondary opening, was carried down around the area of disease, all the way down to the fascia and the whole thing was excised. A probe was placed, and the tract was opened to confirm that the entire tract and abscess cavity had been excised. The wound was irrigated. Hemostasis achieved. The dermis was sutured down to the fascia with 2-0 V

L05.02 pilonidal sinus with abscess 11772 Excision Pilonidal Cyst/sinus Compli

OPERATIVE REPORTSEX: MaleAGE: 52DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Pilonidal cyst (sinus).POSTOPERATIVE DIAGNOSIS: Pilonidal cyst (sinus).PROCEDURE PERFORMED: Pilonidal sinus cyst with marsupializationANESTHESIA: Spinal.SKIN PREP: Betadine.DRAINS: None.DESCRIPTION OF PROCEDURE: The patient was prepped and draped. An elliptical incision was made around the sinus tract opening and carried down around the pilonidal cystic disease, totally excising it. Hemostasis was achieved. The wound was irrigated and closed by marsupialization with interrupted 2-0 Vicryl. It was packed with saline-soaked 4x4 gauze and covered with a dry dressing and the patient was then taken to the recovery room in satisfactory condition having tolerated the procedure well. Sponge, instrument and needle counts were reported as correct.Cohen Andrews, MDElectronically signed by COHEN ANDREWS, MD 1/1/20XX

L05.92 11770

ESTABLISHED PATIENT - OFFICESEX: FemaleAGE: 45DOS:1/1/20XXCC: Skin CheckHPI: Patient returns for her skin check. Patient was previously diagnosed with Melanoma and was referred to Dr. Jones for treatment. Also had lymph node removed and the melanoma was not found in the lymph node. Patient mentions some lesions on L Leg that do not hurt or itch. They have been there for a while.Allergies: No Known Drug Allergies.Current Meds.Vivelle 0.1 MG/24HR PTTW; RPTAlbuterol Sulfate HFA; RPTVentolin HFA 108 (90 Base) MCG/ACT Inhalation Aerosol Solution; INHALE 2 PUFFS EVERY 4 HOURS AS NEEDED FOR COUGH AND WHEEZE.; RxTrazodone HC1 100 MG Oral Tablet; TAKE 0.5 TABLET BEDTIME; RPTTramadol HC1 50 MG Oral Tablet; TAKE 1 TABLET EVERY 12 HOURS AS NEEDED.; RxHydroxyzine HC1 5 MG Oral Tablet; TAKE 1 TABLET 3-4 TIMES DAILY.; RxCyclobenzaprine HC1 5 MG Oral Tablet; Take 1 tablet 2-3 times a day as needed for muscle spasm. May cause drowsin

L30.9Dermatitis, unspecified D23.72Other benign neoplasm of skin of lef Z85.820Personal history of malignant melano 99213 Office/outpatient Established Low Md

OFFICE - NEWSEX: MaleAGE: 21DOS: 1/1/20XXCC: complaint of acne and wartsHPIDuration: 1 yearModifying Factors: has tried compound W and OTC freezingLocation: R and L handsAlso mentions acne on the face. He does not really get big acne lesions.ROSSystemic: Not feeling tired or poorly. No fever, no chills, no night sweats, no recent involuntary weight loss, and no involuntary recent weight gain.Head: No Headache.Neck: No swollen glands in the neck.Eyes: No vision problems.Otolaryngeal: No earache, no nasal discharge, no nasal passage blockage, no sneezing, no hoarseness, no sore throat, and no bleeding gums.Cardiovascular: No chest pain or discomfort and no palpitations.Pulmonary: No dyspnea, no cough, not coughing up sputum, and no wheezing.Gastrointestinal: No dysphagia, no heartburn, no vomiting, and no abdominal pain.Genitourinary: No increase in urinary frequency. No dysuria.Endocrine: No feeling weak.Hematologic:

L70.0Acne vulgaris B07.8Other viral warts 99203 25 Office/outpatient New Low Mdm 30-44 17110 Destruction Benign Lesions Up To 14

OPERATIVE REPORTSEX: MaleAGE: 30DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Left mandibular sebaceous cyst.POSTOPERATIVE DIAGNOSIS: Same.PROCEDURE PERFORMED: Excision of left mandibular sebaceous cyst.ANESTHESIA: 1% Lidocaine with Epinephrine.DESCRIPTION OF PROCEDURE: The skin was prepped with Betadine and then draped. The skin around the 1 cm lesion was infiltrated with the lidocaine. Then an elliptical incision was made around the lesion and carried down into the subcutaneous tissue. The lesion was completely removed. A small bleeding point was controlled with a figure of eight 3-0 Vicryl. The subcutaneous tissue was reapproximated with 3-0 Vicryl and the skin was closed with a 4-0 subcuticular. Tegaderm was applied for a dressing.Cohen Andrews, MDElectronically signed by COHEN ANDREWS, MD 1/1/20XX

L72.3 12051 11441 LT

Jenny SmithAGE: 43DOS: 1/1/20XXPrivate Payer (Medicare rules for 65 and older)ESTABLISHEDCHIEF COMPLAINT: Acne cheeks, cyst scalpHPI:Rash/skin lesion acne. Reported by patient. Location: cheeks.Quality: not itchy; not painful; not bleeding; decreasing in size; stable; getting lighter.Severity: mild.Duration: has noted for <1 week; this AM.Onset/Timing: abrupt onset.Context: no new detergents or skin products; no one else with similar rash/ not scratching.Associated Symptoms: no fever; no cold symptoms; no nausea; no vomiting; no diarrhea; no urinary symptoms; no chills; no fatigue; no change in weight.Treatment History: no history of treatment.PROBLEMS: None recorded. ALLERGIES: Reviewed Allergies. NKDA.MEDICATIONS:MEGESTROL 40 MG TABPAST MEDICAL HISTORY: Reviewed Past Medical History: Hypertension: Y.VITALS: Height: 5'7". Weight: 134 lbs 4 oz. BMI: 21. BP: 119/72 sitting L arm. Pulse: 52 bpm. RR: 22. O2Sat: 99% Room

L72.3 Sebaceous cyst L70.9 Acne, unspecified 99212 Office/outpatient Established Sf Mdm

OPERATIVE REPORTSEX: FEMALEAGE: 51DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: SEBACEOUS CYST VS LIPOMA.PROCEDURES: EXCISION AND BIOPSY OF MULTIPLE SOFT TISSUE MASSES; ONE WAS LOCATED IN THE SOFT TISSUE JUST 3 CM LEFT AT THE MIDLINE ON THE NECK, THE SECOND WAS LOCATED ON THE LEFT SHOULDER AND THE THIRD WAS IN THE LEFT AXILLA.POSTOPERATIVE DIAGNOSIS: SEBACEOUS CYST.SURGEON: MENO E KRAMER, M.D.ANESTHESIA: MASK.ESTIMATE BLOOD LOSS: LESS THAN 5 CC.IV FLUIDS: APPROXIMATELY 400 CC OF LACTATED RINGER'S.URINE OUTPUT: NIL.DRAINS: NONE.COMPLICATIONS: NONE.INDICATIONS: This is a 51-year-old woman who presented to the clinic complaining of several soft tissue masses which she said bothered her. She received preoperative CAT scan to ensure that there was no thyroid involvement of the neck mass. It was determined that it was not thyroid, not brachial cleft cyst but simply soft tissues to the piriform. The risks, benefits and

L72.3Sebaceous cyst 11420 LT Exc B9 Lesion Mrgn Xcp Sk Tg S/n/h/ 11400 LT Exc B9 Lesion Mrgn Xcp Sk Tg T/a/l 0 11400 59,LT Exc B9 Lesion Mrgn Xcp Sk Tg T/a/l 0

OPERATIVE REPORTSEX: MaleAGE: 66This payer requires LT/RT modifierDATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Persistent left ankle ulcer.POSTOPERATIVE DIAGNOSIS: Persistent left ankle ulcer.PROCEDURE PERFORMED: Application of Apligraf, left ankle.ANESTHESIA: None.INDICATIONS: Patient presents with a medial ankle wound. The wound has had significant problems healing despite multiple different taps and several different venous interventions. Today, we plan an Apligraf application. The left medial ankle wound measures 1.5 cm and is 1.9 cm wide. It is 0.3 cm deep. It was debrided by a nurse and his compliance has been excellent.DESCRIPTION OF PROCEDURE: Under sterile conditions, the Apligraf was removed. Sterile saline was placed in the bed of the agar. I then placed a moist gauze on the base of the wound and lifted this from the agar. I crosshatched the Apligraf and placed a double laye

L97.329 15271 LT

OFFICE - NEW PATIENT Radiology (Global Billing)SEX: FEMALEAGE: 74DOS: 1/1/20XXMD: Dr. Brandon AndrewsCHIEF COMPLAINT: Right hip pain.HISTORY:The patient is a female new patient with a longstanding history of right hip pain, probably ten or more years. It is severe now. She reports a severe grinding sensation in the hip and groin. She has been using a walker for the past six months. She saw the spine surgeon who diagnosed advanced osteoarthritis and was referred here for a total hip replacement.PAST MEDICAL HISTORY: Thyroid disease, diabetes, hypertension and osteoarthritis.PAST SURGICAL HISTORY: Hysterectomy and tubal ligation.MEDICATIONS:Victoza, alprazolam, Metoprolol, Actonel, Livalo, Synthroid, aspirin and over-the-counter supplements.ALLERGIES: BACTRAM and CODEINE.SOCIAL HISTORY: Negative tobacco and alcohol.REVIEW OF SYSTEMS: Positive for joint pain, otherwise negative.PHYSICAL EXAMINATION:On exam, the patient

M16.0 Bilateral primary osteoarthritis of 99203 25 Office/outpatient New Low Mdm 30-44 73522 Radex Hips Bilateral with Pelvis 3-4

OPERATIVE REPORTOrthopedic Group GeneralSEX: MAGE: 85Date of Service: 1/1/20XXInsurance: MedicarePREOPERATIVE DIAGNOSIS: Primary Osteoarthritis of the right hipPOSTOPERATIVE DIAGNOSIS: Primary Osteoarthritis of the right hipNAME OF PROCEDURE: Right total hip arthroplastyComputer assisted navigation FluoroscopySURGEON: Brandon Andrews, MDANESTHESIA: GeneralANESTHESIOLOGIST: Bob Thompson, MDESTIMATED BLOOD LOSS: 750 mLCOMPLICATIONS: NoneDRAINS: ConstaVac reinfusion drainIMPLANT: Stryker Accolade II, #6 stem, 58 mm Tritanium cup, 36 mm +5 mm Biolox head.INDICATIONS: The patient is an elderly male with a long-standing history of right hip pain secondary to advanced primary osteoarthritis. He has failed conservative management. He is a fall risk. He is presenting for right total hip arthroplasty. The risks, benefits, alternatives, and potential complications were discussed in detail. Informed consent was obtained.DESCRIPT

M16.11 Unilateral primary osteoarthritis, r 27130 RT Total Hip Arthroplasty 0054T1 Cptr-asst Muscskel Navigj Ortho Fluo

Age: 81SEX: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group GeneralPREOPERATIVE DIAGNOSIS: Severe Primary osteoarthritis of the right hip.POSTOPERATIVE DIAGNOSIS: Severe Primary osteoarthritis of the right hip.NAME OF PROCEDURE: Right AML press-fit metal on metal total hip arthroplasty.SURGEON:ASSISTANT:DESCRIPTION OF PROCEDURE: The patient was given 2 grams of Ancef IV, a spinal anesthetic, then a general anesthetic for the procedure. Foley catheter was placed in the bladder. The patient was placed in the left lateral position where his right hip and lower extremity were prepped and draped in the usual sterile fashion. Space suits were used. A straight lateral approach was made and carefully carried down to the fascia lata, which was split, bleeders were cauterized, a Charnley retractor was placed. The anterior one-half of the gluteus medius and minimus free from the greater trochanter, capsule was

M16.11 Unilateral primary osteoarthritis, r 271301 RT Total Hip Arthroplasty

Age 68Sex: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group GeneralPREOPERATIVE DIAGNOSIS: Arteriovenous malformation with severe primary osteoarthritis of the right hip.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE: Right total hip arthroplasty.SURGEON:ANESTHESIA: GeneralDESCRIPTION OF PROCEDURE: The patient was taken to the operating room and after satisfactory general anesthesia the patient had an intrathecal block performed for postoperative pain control he was placed in the lateral decubitus position with his right hip uppermost. The right hip was then thoroughly scrubbed, prepped and draped in the usual sterile manner. The hip was incised longitudinally down to the fascia lata which was also split. This was retracted and the hip identified. The anterior half of the abductors were incised at the insertion of the greater trochanter. The leg was externally rotated. The capsule was then identifie

M16.11 Unilateral primary osteoarthritis, r M85.451N/SSolitary bone cyst, right pelvis Q27.30N/SArteriovenous malformation, site uns 27130 RT Total Hip Arthroplasty

OPERATIVE REPORTSEX: MaleAGE: 58This payer requires RT and LT ModifiersDate of Service: 1/1/20XXOrthopedic Group SurgeryProvider: Dr. Brandon AndrewsPREOPERATIVE DIAGNOSIS: Posttraumatic arthritis, right hip.POSTOPERATIVE DIAGNOSIS: Posttraumatic arthritis, right hip.NAME OF PROCEDURE:1. Right total hip arthroplasty.2. Computer-assisted navigation includes fluoroscopy.SURGEON: Brandon Andrews, MDANESTHESIA: SpinalANESTHESIOLOGIST: Bob Thompson, MDESTIMATED BLOOD LOSS: 300 mLCOMPLICATIONS: None.DRAINS: ConstaVac reinfusion drain.IMPLANT: Stryker Accolade 2, #5 stem, 60 mm Tritanium cup, 36 mm, -2.5 Biolox head.INDICATIONS FOR PROCEDURE: The patient is a male with posttraumatic arthritis of his right hip following an acetabular fracture in the early 1980s. He is presenting for right total hip arthroplasty. The risks, benefits, alternatives, and potential complications were discussed in detail. Informed consent was obta

M16.51 Unilateral post-traumatic osteoarthr 27130 1 RT Total Hip Arthroplasty 0054T1 Cptr-asst Muscskel Navigj Ortho Fluo

OFFICE-PROCEDURESEX: MAGE: 51DOS: 1/1/20XXMD: Dr. Brandon AndrewsULTRASOUND GUIDED NEEDLE PLACEMENTJay SmithULTRASOUND GUIDED: Right Knee.REASON FOR EXAMINATION: RightDIAGNOSIS:1. Knee pain, right knee.2. Primary Osteoarthritis, right knee.OBJECTIVE: Right knee.TREATMENT PLAN: Hyalgan, 2 injections given today under sterile conditions.Followup in one week. Patient was instructed to contact our office for any adverse reaction.The skin overlying the right knee was prepped with Betadine and alcohol in the routine fashion. 1% Xylocaine was instilled into the soft tissues.Under ultrasound guidance using the BK Medical flex focus 400MSK ultrasound machine, a 22-gauge needle was advanced into the right knee. A combination of Xylocaine anesthetic andHyalgan 1 dose x 2 was introduced into the joint without difficulty. The patient tolerated the injection well.IMPRESSION: Successful right knee injection under ultrasound guidanc

M17.11 20611 RT J7321 J7321

OFFICE PROCEDURESEX: FAGE: 78DOS: 1/1/20XXMD: Dr. Brandon AndrewsULTRASOUND GUIDED NEEDLE PLACEMENT IN OFFICEJane SmithULTRASOUND GUIDED: Left kneeREASON FOR EXAMINATION: Left Knee PainDIAGNOSIS:1.Knee Pain2.Primary Osteoarthritis of knee.OBJECTIVE: Left kneeTREATMENT PLAN: Hyalgan. 1 Injection (1 dose) given today under sterile conditions.FOLLOW UP: In 1 week. Patient was instructed to contact our office for any adverse reaction.The skin overlying the left knee was prepped with Betadine and alcohol in the routine fashion. 1% Xylocaine was instilled into the soft tissues.Under ultrasound guidance using the BK Medial flex focus 400MSK ultrasound machine, a 22-gauge needle was advanced into the left knee. A combination of Xylocaine anesthetic and Hyalgan (1 dose) was introduced into the joint without difficulty. The patient tolerated injections well.IMPRESSION: Successful left knee injection under ultrasound guidance.B

M17.12 20611 LT J7321

SEX: MAGE: 71DOS: 1/1/20XXThis is a Commercial Payer (Follow Medicare rules for 65 and older). MD: Dr. Brandon AndrewsCHIEF COMPLAINT: Right knee pain.HISTORY: The patient is a male with a history of an anterior cruciate ligament tear and MCL tear with subsequent reconstruction. The patient has done very well. His injury and surgery was in 20XX. Over the last year or so he reports progressive knee pain and symptoms. For the last six months it has been rather significant. He complains of pain through the medial compartment, crepitation but no frank locking. It is affecting his ability to exercise. He recently saw Dr. Scott Jones who ordered a CAT scan and was concerned about a meniscus tear. He ordered a CAT scan due to metal interference screws.PAST MEDICAL HISTORY: Denies.PAST SURGICAL HISTORY: Appendectomy and ACL reconstruction.MEDICATIONS: Multivitamins.ALLERGIES: Penicillin.SOCIAL HISTORY: Negative tobacco. Occa

M17.31 M22.41 Z98.890 Z96.698 99203 25 20611 RT J7321

OPERATIVE REPORTOrthopedic Group GeneralDr. Brandon AndrewsSex: FAGE: 70Date of Service: 1/1//20XXThis is a Commercial Payer (Follow Medicare rules for 65 and older). Insurance: MedicareOPERATIVE NOTE:PREOPERATIVE DIAGNOSES: Right knee lateral meniscus tear - Degenerative joint diseasePOSTOPERATIVE DIAGNOSIS: Right knee lateral meniscus tear - Degenerative joint diseaseNon-repairable vertical medical meniscus tearNAME OF PROCEDURES: Right knee arthroscopy with partial medial and lateral meniscectomiesChondroplasty of the medial and lateral compartmentsSURGEON: Brandon Andrews, MDANESTHESIA: GeneralANESTHESIOLOGIST: Bob Thompson, MDESTIMATED BLOOD LOSS: MinimalCOMPLICATIONS: NoneINDICATIONS FOR PROCEDURE:Patient is a female with chronic right knee pain and mechanical symptoms due to meniscus pathology. She is presenting for arthroscopic right knee surgery. The risks, benefits, alternatives, and potential complications

M23.321 M17.11 M23.341 M94.261 29880

OFFICE - NEW PATIENTSEX: FEMALEAGE: 85DOS: 1/1/20XXThe payer requires the 50 modifier be used.MD: Dr. Brandon AndrewsCHIEF COMPLAINT: Bilateral knee pain.HISTORY: The patient is new to my practice, a female with a longstanding history of bilateral knee pain, left more than right. She has had progressive pain isolated to the medical compartment. She states it got a lot worse after her recent chemotherapy for breast cancer. The pain is located medially, it swells. There is no locking or catching. She cannot take NSAIDs. She developed a bleeding ulcer from Indocin. She has had a couple series of HA injections which were temporary but gave her some improvement. The patient would like to pursue definitive management in the form of knee replacement. She is scheduled to go on vacation for two months and was hoping to have it done this September.PAST MEDICAL HISTORY: Hypertension, osteoarthritis and breast cancer.PAST SURGIC

M25.462 M17.9 99202 25 20611 LT 73562 50 J3301 J3301 J3301 J3301

OFFICE - ESTABLISHEDSEX: FEMALEAGE: 69DOS: 1/1/20XXCHIEF COMPLAINT: Left shoulder problem. Left shoulder pain x 2 weeks.HPI:Shoulder. Reported by patient. Hand Dominance: right. Location: left; anterior. Quality: aching. Severity: pain level 7/10; worst pain 9/10. Duration: 2 weeks. Timing: chronic. Context: cannot identify. Alleviating Factors: lifting; carrying; pushing/pulling. Associated Symptoms: no weakness; no numbness; no catching/locking; no grinding; no fever. Previous Surgery: none. Previous Injections: none. Previous PT: none. Work Related: no. Working: no.PROBLEMS: Problems Not Reviewed (last reviewed 1/21/20XX).• Niddm controlled• Obesity• Anxiety• Hypertension controlled• Pain in joint - shoulderALLERGIES: Reviewed Allergies: NKDA.MEDICATIONS: Reviewed Medications:ACETAMINOPHEN 300 MGADVAIR DISKUS 500 MCG-50ALBUTEROL SULFATE HFA 90 MCGAMPICILLIN 500 MG CAPCARVEDILOL 12.5 MG TABCOREG 25 MG TAB

M25.512 Pain in left shoulder E11.9 Type 2 diabetes mellitus without com Z79.84 Long term (current) use of oral hypo 99213 25 Office/outpatient Established Low Md 963721Therapeutic Prophylactic/dx Injectio J18851N/SKetorolac Tromethamine Inj J18851N/SKetorolac Tromethamine Inj J18851N/SKetorolac Tromethamine Inj J18851N/SKetorolac Tromethamine Inj

OFFICE - ESTABLISHED Radiology (Global Billing)SEX: FEMALEAGE: 66DOS: 1/1/20XXMD: Dr. Brandon AndrewsCHIEF COMPLAINT: Left hip pain and lower left leg weakness.HISTORY: The patient is seen in the office with a problem regarding her left hip and weakness in her leg. For the past month she reports pain in the left hip. It is sporadic. It is associated with bending forward and when she sits and stands from a seated position. She denies any pain with trying to put her shoes and socks on. She feels as though her left leg is weak. It is dragging. Her left foot is glued to the ground. She does report a prior history of sciatica. She is currently denying any numbness or tingling or low back symptoms.PHYSICAL EXAMINATION:On examination, the hip has near full range of motion on the right hip without pain. The left hip is restricted. She has pain with left straight leg raise of the upper thigh and buttock area. Her motor and se

M25.552 Pain in left hip R53.1 Weakness 99213 25 Office/outpatient Established Low Md 73503 LT Radex Hip Unilateral with Pelvis Min

SEX: MaleAge: 68Date of Service: 1/1/20XXService Department: OrthopedicProvider:OPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Previous spinal fusion at the L5-S1 level with stenosis of a previous fusion at L4-L5.POSTOPERATIVE DIAGNOSIS: Previous spinal fusion at the L5-S1 level with stenosis of a previous fusion at L4-L5 with claudicationNAME OF PROCEDURE: Repeat spinal surgery. Lumbar laminotomy L4-5 with foraminotomy.SURGEON:ANESTHESIA: General.ESTIMATED BLOOD LOSS: Negligible.COMPLICATIONS: None.INDICATIONS: Severe lower back pain radiating down the left lower extremities towards the foot, paresthesias, dysesthesias and claudication difficulty with walking. Positive straight leg raising.IMAGING STUDIES: Previous fusion L5-S1. MRI study and myelogram showing that at L4-5 he has relatively good disk type remaining, not a lot of instability, posterior stenosis.RECOMMENDATIONS: I have encouraged the patient to live with his

M48.062 Z98.1 630422

AGE: 67Sex: FDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: HERNIA DISC L4-5.PROCEDURES: L4-5 LAMINECTOMY, MEDIAL FACETECTOMY AND DISCECTOMY.POSTOPERATIVE DIAGNOSIS: HERNIA DISC L4-5 LT SIDESURGEON:ANESTHESIA: GENERAL, ENDOTRACHEAL.INDICATIONS: This is a woman with severe leg pain, difficulty walking, weakness of the left leg reflexion of the foot, straight leg raising exam was positive. Imaging study showed a very large, extruded disc herniation L4-5 compression of the thecal sac. The patient was scheduled for surgery. After discussing the risks, benefits and possible complications of procedure, wished to proceed.PROCEDURE: The patient was brought to the operating room and placed in the supine position. After appropriate monitoring lines and Foley catheter was placed, she was given general anesthesia and turned to the prone position on the Wilson frame. The back was prepped and draped in usual fashion. Localizin

M51.26 Other intervertebral disc displaceme 63030 LT Lamnotmy Incl W/Dcmprsn Nrv Root 1 I

OPERATIVE REPORTSEX: MALEAGE: 75Date of Service: 1/1/20XXProvider: Dr. Brandon AndrewsOPERATIVE REPORT:PREOPERATIVE DIAGNOSIS:1. L4-5 spinal stenosis and spondylolisthesis.2. Lateral listhesis.3. Spondylosis.4. Disk herniation.5. L3-4 stenosis, Spondylosis.6. Instability of lumbar spine.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE: Left-sided L4-5 laminectomy, diskectomy, medial facetectomy, foraminotomy, and dorsalcorpectomy.SURGEON: Brandon Andrews, MDASSISTANT: Anne Jones, PA-CANESTHESIA: General.ESTIMATED BLOOD LOSS: Less than 10 mL.COMPLICATIONS: None.DISPOSITION: Stable to recovery room and then to the floor. When stable and ambulatory, may be discharged home.INDICATIONS: This elderly gentleman, taken care for several years now. He has suffered from back pain with left lower extremity pain. The distribution of symptoms are lateral thigh and calf, dorsal foot very clearly in L5 pattern.He has had a good respo

M51.26Other intervertebral disc displaceme M47.816N/SSpondylosis without myelopathy or ra M43.16Spondylolisthesis, lumbar region M48.061Spinal stenosis, lumbar region witho 63030 LT Lamnotmy Incl W/Dcmprsn Nrv Root 1 I

OFFICE VISIT - EST Sex: MAGE: 44DOS: 1/1/20XXSUBJECTIVE: The patient is a male being seen for lumbar back pain. The symptoms have been gradual in onset with a severity of 6/10 in pain score. This lumbar back pain is also associated with headaches. Both sides are affected equally. He has had no history of surgery .OBJECTIVE: On exam, he has diffuse lower lumbar back pain and headache PLAN: The patient will need a lumbar AP and lateral plain film for further evaluation. Patient to return to office after obtaining further studies or if symptoms get worse David Kramer, MD Electronically signed by DAVID KRAMER, MD 1/1//20XX Case ID : OPD7206

M54.50 Low back pain, unspecified R51.9 Headache, unspecified

OFFICE VISIT - ESTABLISHED GLOBAL PERIODPOST PROCEDURESurgery 7 days ago, with Dr. Kramer as surgeonSEX: FEMALEAGE: 68DOS: 1/1/20XXSUBJECTIVE: The patient underwent a T7 kyphoplasty approximately one week ago for a 5-year-old compression fracture of T7. She states the bone pain has completely resolved; however, she is having severe intermittent back muscle spasm located at the level of the bra strap, which is 6-8 inches below the site. She is on Soma for this but this does not appear to have solved her spasm problems.OBJECTIVE: On exam, the kyphoplasty sites are healing well. No erythema or fluctuance.IMPRESSION: Status post T7 kyphoplasty seven days ago with complete resolution of bone pain but with significant muscle spasms unrelieved by Soma.PLAN: She will be seeing Dr. Jones, her PCP in the next two hours as well today. I have called Dr. Jones and left a message regarding the spasms. Hopefully he can be of assist

M62.830 Z47.89 99024

OPERATIVE REPORTSEX: MALEAGE: 48DATE : 1/1/20XXPREOPERATIVE DIAGNOSIS: INTERNAL DERANGEMENT - LEFT KNEE.PROCEDURES: DIAGNOSTIC AND OPERATIVE ARTHROSCOPY - LEFT KNEE.1. SYNOVECTOMY - MAJOR.2. CHONDROPLASTY - PATELLOFEMORAL JOINT.POSTOPERATIVE DIAGNOSIS: 1. CHONDROMALACIA GRADES 3 AND 4 - PATELLOFEMORAL JOINT LEFT KNEE; 2. ACUTE AND CHRONIC SYNOVITIS.SURGEON: Ignacio Kramer, M.D.FIRST ASSISTANT:ANESTHESIA: LOCAL WITH INTRAVENOUS SEDATION.ANESTHESIOLOGIST: HARRIET ANDREWS, M.D.PROCEDURE: After adequate induction with intravenous sedation and the patient in the supine position, the left lower extremity was scrubbed, prepped with Betadine and draped in the usual manner for arthroscopic surgery. A few cc of 1% lidocaine with epinephrine was injected into the primary portal sites including superolateral, anterolateral and anteromedial. In addition, 40 cc of 0.25% bupivacaine was instilled in the joint. Instrumentation was s

M65.862 M22.42 29876 LT

OPERATIVE REPORTSEX: MALEAGE: 70DATE OF OPERATION: 1/1/20XXThis payer requires the LT or RT modifierPREOPERATIVE DIAGNOSIS: INFECTED PRE-PATELLA BURSA, LEFT KNEE STATUS POST QUAD TENDON DUE TO REPAIR ONE YEAR AGO.PROCEDURES: INCISION, DRAINAGE AND DEBRIDEMENT.POSTOPERATIVE DIAGNOSIS: SUTURE GRANULOMA PRE-PATELLA BURSA, LEFT KNEE STATUS POST QUAD DUE TO TENDON REPAIR ONE YEAR AGO.SURGEON: Loren Kramer M.D. ANESTHESIA: GENERAL, LARYNGEAL MASK AIRWAY.ANESTHESIOLOGIST: Sarah Andrews, M.D. ESTIMATED BLOOD LOSS: MINIMAL.TOURNIQUET TIME: 8 MinutesCOMPLICATIONS: NONE.PROCEDURE: After the patient was given the risks, benefits, ramifications and postoperative expectations regarding the left knee I&D, signed consent, brought back to the operating room, given general laryngeal mask airway and 1 gm of Ancef. The left lower extremity was prepped and draped in the usual sterile manner.An incision was made through a previous incisio

M70.42 T81.89XA Z98.890 27301 LT 11044 LT

OPERATIVE REPORTSEX: FEMALEAGE: 73DOS: 01/0/20XXPREOPERATIVE DIAGNOSIS: RIGHT L5-S1 SYNOVIAL CYST.PROCEDURES: RIGHT L5-S1 LAMINOTOMY FOR EXCISION OF SYNOVIAL CYST.POSTOPERATIVE DIAGNOSIS: RIGHT L5-S1 SYNOVIAL CYST.SURGEON: Archie Jones, M.D.ANESTHESIA: GENERAL, ENDOTRACHEAL.ESTIMATE BLOOD LOSS: 150 CC.IV FLUIDS: 1300 CRYSTALLOIDS.URINE OUTPUT: 500 CC.COMPLICATIONS: NONE.DISPOSITION: THE PATIENT WAS AWAKE AND EXTUBATED IN SURGERY TAKEN TO POSTANESTHESIA CARE UNIT IN STABLE CONDITION HAVING TOLERATED THE PROCEDURE WELL.INDICATIONS: The patient is a female who presented to the outpatient neurosurgery clinic with severe leg pain and imaging study, which showed a large lesion arising from the right L5-S1 facet causing severe canal compression. I discussed with the patient, the options of treatment and the recommendation for surgery of this most likely a synovial cyst. The patient understood all the risks and options and w

M71.38Other bursal cyst, other site 63267 Lam Exc/evac Ispi Lesion Oth/thn Neo 69990 Microsurg Tqs Req Use Operating Micr

EMERGENCY DEPARTMENTSex: FemaleAGE: 55DOS: 1/1/20XXCC: Heel PainHISTORY OF PRESENT ILLNESS: The patient is a female who presents to the emergency department with concerns over heel pain to the right heel noted over the last 6 weeks. The pain to the heel has increased today. She finds it difficult to walk. Sleeping has been a problem. She is not sure if it is positional or discomfort when the sole of the foot is palpated or pressure is placed upon the foot in that area. There has been no swelling. No injury. No numbness and tingling to the extremity. She attempts to change positions frequently during the day, and she rotates the shoes that she wears to work. She does work 12 hour shifts, standing a significant part during her workday. There is no prior history to this heel.PAST MEDICAL HISTORY: Negative.FAMILY HISTORY: Positive for cancer, heart disease, mesothelioma.SOCIAL HISTORY: Positive for alcohol use. She is em

M72.2 Plantar fascial fibromatosis 99283 Emergency department visit for the e

OFFICE - ESTABLISHEDKevin SmithAGE: 48DOS: 1/1/20XXMD: Dr. Brandon AndrewsThe patient returns four months out from arthroscopic decompression. She has had a significant setback. She is uncertain what happened. She was prescribed Cymbalta. She apparently slept for eighteen hours. When she woke up she was in severe pain. At her last visit she was near 90% improved with very little pain. She has been doing home exercises.EXAMINATIONS:On examination, she has a painful restricted area and positive Neer and Hawkins impingement tests today. Her rotator cuff strength is well-maintained.DIAGNOSIS: Status post right shoulder arthroscopy with ongoing impingement findings.TREATMENT:The patient was offered a subacromial cortisone injection. She appears to be inflamed. She has bursitis and residual impingement. I am uncertain what happened. She was doing very well. In any event, she has agreed to a subacromial cortisone injection.

M75.41 M75.51 Z98.890 99213

OFFICE - ESTABLISHEDSEX: FEMALEAGE: 54DOS: 1/1/20XXMD: Dr. Brandon AndrewsThe patient returns for her right shoulder impingement syndrome and possible rotator cuff tear that was diagnosed by ultrasound by another physician. She has undergone an MRI scan which I personally reviewed. The patient continues to report significant pain. She cannot sleep at night. She cannot lift her arm up.EXAMINATION:On examination, there is moderate tenderness through the AC joint and rotator cuff insertion. She has restricted motion in all planes, a positive Neer and Hawkins impingement test, weakness and pain noted with resistance testing of the supraspinatus.IMAGING STUDIES:Her MRI scan is reviewed and reveals moderate AC joint degenerative changes with marrow edema and impingement on the rotator cuff. The rotator cuff is intact.DIAGNOSIS:1. Impingement syndrome, RT shoulder.2. AC joint primary degenerative osteoarthritis Rt ShoulderT

M75.41 Impingement syndrome of right should M19.011 Primary osteoarthritis, right should 99213 Office/outpatient Established Low Md

Emergency Department ReportSex: MaleAGE: 16DOS:01/01/20XXCHIEF COMPLAINT: Elbow pain.HISTORY OF PRESENT ILLNESS: This is a male who, in Baseball game was pitching a ball hard and heard a pop in his elbow with subsequent soreness with range of motion or palpation since. He denies numbness or tingling. Denies any shoulder pain. Denies any prior similar problems. He has had somewhat similar pain in the past after he pitches too much or throws too hard. In fact his father states he has been telling him about warming up properly, etc. The patient states he warmed up well today. He denies any chest pain or abdominal pain. No neck pain or other problems.PAST MEDICAL HISTORY: Unremarkable.MEDICATIONS: The patient had some ibuprofen but is not on medications regularly.ALLERGIES: HE HAS NO ALLERGIES.SOCIAL HISTORY: The patient is here with his father. He is a student. He has been playing baseball.PHYSICAL EXAM: VITAL SIGNS: No

M77.11 Lateral epicondylitis, right elbow W21.03XA Struck by baseball, initial encounte Y92.320 Baseball field as the place of occur Y93.64 Activity, baseball 99283 Emergency department visit for the e

Age: 58Sex: FDate of Service: 1/1/20XXService Department: Orthopedic Group GeneralProvider: Dr.OPERATIVE NOTE:PREOPERATIVE DIAGNOSIS: Chronic lateral epicondylitis in the left elbow.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE: Lateral tennis elbow release, left elbow.SURGEON:DESCRIPTION OF PROCEDURE: The female patient was taken to the operating room and after satisfactory regional anesthesia, the left elbow was thoroughly scrubbed, prepped, and draped in the usual manner. A longitudinal incision was made overlying the later aspect of the elbow. The incision was deepened through the subcutaneous tissue through the epicondyle. The epicondyle area was exposed by dissecting through the rather extensive subcutaneous fatty tissue. The interval between the common extensor and the ECRB was identified. The common extensor was reflected and the underlying ECRB had an area of necrosis. This was excised. The remaining tendo

M77.12 Lateral epicondylitis, left elbow 24359 LT Tnot Elbow Lateral/medial Debride Op

OPERATIVE REPORTOrthopedic Group GeneralSEX: FAGE: 75Date of Service: 1/1/20XXThis is a Commercial Payer (Follow Medicare rules for 65 and older)Dr. Brandon AndrewsPREOPERATIVE DIAGNOSIS: Left distal calf organized painful hematoma.POSTOPERATIVE DIAGNOSIS: Same.NAME OF PROCEDURE: Excision of organized hematoma with drainage and local fasciotomy.SURGEON: Brandon Andrews, MDASSISTANT: Anne Jones, PA-CANESTHESIA: GENERALDESCRIPTION OF PROCEDURE: The patient was taken to the operating room. After satisfactory general anesthesia, she was placed supine on the operating table and her left leg was sterilely scrubbed, prepped, and draped in usual manner form the knee to the foot. The painful area of the organized hematoma was identified and the point where she indicated maximally tender was particularly identified. The incision was centered over this area and taken for a distance of approximately 3.5 cm total length. The unde

M79.81 27601 LT

OFFICE - NEW PATIENT SEX: MaleAGE: 49DOS: 1/1/20XXMD: Dr. Brandon AndrewsCHIEF COMPLAINT: Bilateral knee pain.NEW PTHISTORY: The patient is a 49-year-old male, avid runner, who has had on and off knee pain bilaterally for over three months. He runs at this time up to fifty miles per week. The patient complains of pain over the anteromedial lower femurs. He also notices some pain in the posterior knee and hamstring area. He denies any mechanical symptoms. He has undergone MRI scans which show stress reaction and bone marrow edema of the distal anterior femur on the right knee and bone marrow edema of the anterior distal femur of the left knee.PAST MEDICAL HISTORY: Denies.PAST SURGICAL HISTORY: Denies.MEDICATIONS: Motrin.ALLERGIES: NoneSOCIAL HISTORY: Negative tobacco and alcohol.PHYSICAL EXAMINATION: On exam, the patient is a pleasant male. His lower extremity alignment is normal. There is no joint effusion. He has ve

M84.38XA X50.0XXA Y93.02 99203 25 73562 50

OPERATIVE REPORTSEX: FemaleAGE: 53This payer requires RT and LT ModifiersDate of Service: 1/1/20XXService Department: Orthopedic Group SurgeryProvider: Dr. Brandon AndrewsPREOPERATIVE DIAGNOSIS: Avascular necrosis right hip.POSTOPERATIVE DIAGNOSIS: Avascular necrosis right hip.NAME OF PROCEDURE:1. Right total hip arthroplasty.2. Computer-assisted navigation.3. Fluoroscopy.SURGEON: Brandon Andrews, MDANESTHESIA: SpinalANESTHESIOLOGIST: Bob Thompson, MDESTIMATED BLOOD LOSS: 500 mLCOMPLICATIONS: None.DRAINS: ConstaVac reinfusion drain.IMPLANTS: Stryker Accolade II, #2 stem, 54 mm Tritanium chest pin, 36 plus 0 Biolox head.INDICATIONS FOR PROCEDURE: The patient is a female with severe right hip pain due to avascular necrosis confirmed for radiographs and magnetic resonance imaging scan. She is presenting for right total hip arthroplasty having failed conservative treatment. The risks, benefits, alternatives, and potentia

M87.051 Idiopathic aseptic necrosis of right 27130 RT Total Hip Arthroplasty 0054T Cptr-asst Muscskel Navigj Ortho Fluo

OFFICE - ESTABLISHEDSEX: FemaleAGE: 54DOS: 1/1/20XXCC: Follow upHISTORY OF PRESENT ILLNESS: We had put her on Toviaz 4 mg daily and some antibiotics and had her return today for evaluation following her CT scan. She has done very well on the Toviaz. We went over the CT scan report with her and it did point out that there was fatty infiltration of the liver that had changed since her last exam and apparently they were very concerned about it from a radiology point of view. I encouraged her to see her family physician and take the report with her and see what they say. Otherwise, she is doing very well with her urinary tract complaints.PAST MEDICAL HISTORY: Reviewed and all pertinent positives explored.Physical exam: Patient is a well-developed and well-nourished female in no acute distress. Neck is supple without thyroid enlargement or lymphadenopathy. Respiratory effort is good. Peripheral pulses are intact. There is

N39.46 Mixed incontinence Z87.440 Personal history of urinary (tract) 99213 Office/outpatient Established Low Md

OPERATIVE REPORTAGE: 39DOS: 1/1/20XXPHYSICIAN: Carrol Andrews, MDPREOPERATIVE DIAGNOSIS: Bilateral macromastia (hypertrophy).POSTOPERATIVE DIAGNOSIS: Bilateral macromastia (hypertrophy).OPERATIVE PROCEDURE: Bilateral reduction mammoplasty. SURGEON: Carrol Andrews, MDANESTHESIA: General. COMPLICATIONS: None. INDICATIONS: Ms. Smith is a female, who presented to the clinic with symptomatic macromastia (hypertrophy). Preauthorization was obtained to perform bilateral reduction mammoplasty. Minimal resection was 800 g. The patient had significant macromastia where I explained that this goal would be easily achieved. The patient agreed and wished to proceed with surgery. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room where she was placed in supine position. She was placed under general anesthesia. Bilateral upper extremities were secured to arm boards with cast padding. Both breasts were marked in

N62 Hypertrophy of breast 193181 mod:50 Breast Reduction

OPERATION REPORTAGE: 22Sex: FDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: RECURRENT RIGHT BREAST MASS.PROCEDURES: EXCISION RIGHT BREAST MASS X 2.POSTOPERATIVE DIAGNOSIS: RECURRENT RIGHT BREAST MASS.SURGEON:ANESTHESIA: LMA AND LOCAL INFILTRATION.PROCEDURE: The patient is a female who has a recurrent mass that was multilobulated in the entire right upper outer quadrant and also a separate mass which was further away from the nipple at a 9 o'clock position. These two were identified. After skin local infiltration anesthesia was given.A curvilinear incision was made around the nipple. The skin flaps were raised, so that the entire large mass was exposed. This was about 2 to 3 cm. The mass was identified below some of the glandula and fat tissue. It was completely excised using sharp dissection knife and with possible margin around. The patient had smaller breast and there was active gland tissue around the area of

N63.11 Unspecified lump in the right breast N63.15 unspecified lump in the right breast 19120 RT Open Excision, Breast Lesion(s), Mal

OPERATIVE REPORTAGE: 37Sex: FDATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsASSISTANT: Nurse.PREOPERATIVE DIAGNOSIS: Abdominal wall endometrioma.POSTOPERATIVE DIAGNOSIS: Abdominal wall endometrioma.PROCEDURE PERFORMED: Excision of the abdominal wall endometrioma.ANESTHESIA: General.DESCRIPTION OF PROCEDURE: The patient was brought into the operating room. The abdomen was prepped and draped in the usual manner. Preoperative surgical site marking was done in ambulatory surgical unit. Preoperative surgical pause was performed in the operating room. A transverse incision was made in the old caesarean section scar. The incision was carried down to the subcutaneous tissue with electrocautery. The endometrial mass was fairly easily palpable and was systematically excised circumferentially with good margins. The fascia was involved. Hemostasis was secure. The endometrioma was totally excised with what appeared to be go

N80.8 22900

OPERATIVE REPORTSEX: FEMALEAGE: 54DATE OF OPERATION: 11/21/20xxHOSPITAL/MR NUMBER: 1234567SURGEON: Dr. O.B. Andrews.PREOPERATIVE DIAGNOSES: Postmenopausal bleedingPOSTOPERATIVE DIAGNOSES: Postmenopausal bleedingPROCEDURES PERFORMED: 1. Hysteroscopy 2. Dilation and CurettageESTIMATED BLOOD LOSS: MinimalANESTHESIA: General COMPLICATIONS: NoneSPECIMENS: Endometrial CurettingsINDICATIONS FOR PROCEDURE: The patient is 54-year-old gravida 7 para 3 who presents complaining of uterine bleeding. The patient states that it has been gradually getting worse over the last 2 years. She states that she bleeds for 2 weeks at a time. She states in the post she has been told that she had fibroids. She also had a uterine ablation 4 years ago. She states this bleeding has been interfering with her otherwise active lifestyle.FINDINGS: Mainly atrophic appearing endometrium although there was a lot of stranding along the endometrial lining

N95.0 Postmenopausal bleeding 58558 Hysteroscopy Bx Endometrium&/polypc

OPERATIVE REPORTSEX: FEMALEAGE: 36DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: HEMATOMA OBSTETRIC WOUNDSTATUS POST NSVD WITH RIGHT MEDIOLATERAL EPISIOTOMY AND THIRD DEGREE EXTENSION.PROCEDURES: EVACUATION OF HEMATOMA, EXPLORATION OF HEMATOMA BED; LIGATION OF BLEEDERS AND REPAIR OF EPISIOTOMY.POSTOPERATIVE DIAGNOSIS: HEMATOMA OBSTETRIC WOUNDSURGEON: Monte Kramer, M.D.FIRST ASSISTANT: ANESTHESIA: CONSCIOUS SEDATION.ESTIMATED BLOOD LOSS: 500 CC.ANTIBIOTICS: PROPHYLAXIS.IV FLUIDS: 250 CC HESPAN ALONG WITH OTHER IV FLUIDS.URINE OUTPUT: 500 CC OF CLEAR URINE.DRAINS: FOLEY.COMPLICATIONS: NONE.DISPOSITION: THE PATIENT TOLERATED THE PROCEDURE WELL.PATIENT CONDITION: STABLE.FINDINGS: Large amount of blood clots and right-sided hematoma extending down into right buttock. Hematoma evacuated. Several figure-of-eight sutures of 0-Vicryl were used to ligate arterial bleeders. Episiotomy reapproximated with 2-0 chromic. Skin r

O90.2 Hematoma of obstetric wound 570221 I&d Vaginal Hematoma Obstetrical/pos 59300 Episiotomy/Vag Rpr Oth/Thn Attending

OPERATIVE REPORTSEX: MaleAGE: 19PREOPERATIVE DIAGNOSES:1. Accessory tarsal, right prominent posterior process of talus with posterior impingement.2. Pain in right ankle in subtalar joint.POSTOPERATIVE DIAGNOSES:1. Accessory tarsal, right prominent posterior process of talus with posterior impingement.2. Pain in right ankle in subtalar joint.3. Synovitis, right ankle.OPERATION:1. Surgical arthroscopy of the right ankle with extensive debridement of synovitis in the distal tibiofibular joint, posterior ankle capsule, and anterior and anterolateral ankle capsule.2. Surgical arthroscopy of the right subtalar joint with partial excision of prominent posterior process of talus.Surgeon: Christopher Thomas, MD1st Assistant: Robert Andrews, M.D., R-3Anesthesia:Indication for Procedure: Markus is a 19-year-old white male who is a football player for Vanderbilt. He sustained an injury in the summer, an ankle sprain. MRI was obt

Q74.2N/SOther congenital malformations of lo M65.871Other synovitis and tenosynovitis, r M76.891N/SOther specified enthesopathies of ri 29906 RT Arthroscopy Subtalar Joint With Debr 29898 RT Arthroscopy Ankle Surgical Debrideme

NEW PATIENTSex: FemaleAGE: 25Date: 01/01/20XXHISTORY OF PRESENT ILLNESS: New female pt, who is 32 weeks pregnant and here for tachycardia, which is not affecting the pregnancy. She has had isolated episodes of this problem prior to pregnancy; however this has become more of an issue over the last several weeks. She notes episodes of tachycardia at rest associated with some shortness of breath. Prior to this, she has been healthy, physically active. She has been obese, weighing approximately 220 pounds prior to her pregnancy. She has not been hypertensive. She has no chest pain.CORONARY RISK FACTORS1. No hypertension.2. She is pregnant.3. Nonsmoker.4. Nondiabetic.5. Glucose tolerance test performed at 28 weeks: Results not available.6. Cholesterol level is not known.PAST MEDICAL AND SURGICAL HISTORYMedical: No cancer. No hepatitis. No periodontal disease. No hospitalizations.Surgical: None.ALLERGIES: No known drug all

R00.0 Tachycardia, unspecified Z33.1 Pregnant state, incidental 99204 25 Office/outpatient New Moderate Mdm 4 93000 Ecg Routine Ecg W/least 12 Lds W/i&r

OFFICE - ESTABLISHEDSEX: FemaleAGE: 25Date: 01/01/20XXCHIEF CONCERN: She is here for medication check.PROBLEM LIST1. She is now 38 weeks pregnant.2. Inappropriate sinus tachycardia.ALLERGIES: known drug allergies.MEDICATIONSChildren's Chewable Vitamins q.d.Folic acid q.d.Iron q.d.B12 p.r.n.Metoprolol succinate 25 mg q.d. (not regularly)INTERVAL HISTORY: This is a pt that had tachycardia before becoming pregnant at last office visit, metoprolol 25 mg a day was added with significant improvement in palpitations. She states she has had three episodes only over the last month that lasted greater than 10 minutes. Occasional minor episodes, but overall much improved; however, she does forget doses approximately two times a week. She has no definite correlation between day's missed and significant episodes, although this is likely.PHYSICAL EXAMINATIONVITAL SIGNS: Weight 218 lbs. BP 108/68 in the left arm, pulse 87 and regul

R00.0Tachycardia, unspecified T44.7X6A Underdosing of beta-adrenoreceptor a Z91.138 Patient's unintentional underdosing Z33.1 Pregnant state, incidental 99213 Office/outpatient Established Low Md

EMERGENCY DEPARTMENTSEX: FEMALEAGE: 79DOS: 1/1/20XXInitial patient contact.Arrived- By private vehicle. Historian- patient.Code only for the Emergency DepartmentHISTORY OF PRESENT ILLNESSChief complaint- DYSPNEA and HISTORY OF CONGESTIVE HEART FAILURE. This started about 1 weeks ago and is still present. The dyspnea is described as moderate. The dyspnea is worsened by walking and exertion, is improved by rest and is improved with sitting upright. She has had dyspnea on exertion, orthopnea and paroxysmal nocturnal dyspnea. No cough, sputum production, fever, sweating episodes or wheezing. No chest pain or discomfort, calf pain, foot swelling or anxiety. No dizziness, tingling, numbness or palpitations. This is a female with hx of CAD, CABG, ischemic cardiomyopathy with CHF requiring pacemaker presents with worsening dyspnea over last week. Pt has had DOE, orthopnea, PND and increased leg swelling. Pt denies any chest

R06.00 I11.0 I50.9 E11.9 Z95.1 Z95.0 99285

Emergency Department Report - Admitted to ObservationSex: FemaleAge: 86DOS: 01/01/20XXTime Seen: 19:05 Jan 01 20XXArrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESSChief Complaint: PALPITATIONS. FAST HEART RATE and DIZZINESS. This started today and is still present. It is described as a fast heart beat. The patient complains of dizziness and weakness. Modifying factors- worsened by walking and exertion. Relieved by rest. She has had difficulty breathing (today). The patient has had dizziness. No chest pain or discomfort, sweating episodes, fainting episodes or tingling. No muscle spasms.Similar symptoms previously: She has had similar symptoms several times previously. (paroxysmal a-fib).Recent medical care: The patient was seen recently at another facility in a clinic. (Sent from PCP office for eval.).REVIEW OF SYSTEMSThe patient has had a cough but not had a poor appetite. No fever, chills,

R06.00 R55 R00.2 R09.02 I51.7 Z79.82 Z95.2 99223 25 93010

RADIOLOGY REPORT LOCATION: Mountain HospitalSEX: MaleAGE: 34DATE OF EXAM: 1/1/20XXPHYSICIAN(S): M.D.PROCEDURE: CHEST TWO VIEWS, PA AND LATERALCOMPARISON: None.INDICATIONS: Chest pain. Shortness of breath.TECHNIQUE: PA and lateral radiographs of the chest were performed.FINDINGS:CARDIAC: Normal.LUNGS: Acute respiratory distress, No focal consolidations.MEDIASTINUM: Trachea is midline. Pulmonary vasculature is unremarkable. Contour is normal.PLEURA: No effusion. No pneumothorax.BONES: Normal for age.OTHER: EKG leads overlie the chest.CONCLUSION: Acute Respiratory DistressElectronically signed by 1/1/20XX

R06.03 71046 26

PROGRESS NOTEAGE: 44Consulting Physician:Referring Physician:Date: 01/01/20XXPROBLEM LIST1. 44-year-old with hypertension, with left ventricular hypertrophy.2. Chest pain.ALLERGIES: Cortisone injections (cause nausea).MEDICATIONSLisinopril 60 mg q.d.Tylenol p.r.n.Xopenex q.d.INTERVAL HISTORY: The patient has not been seen in this office for 11 months. He presented to the emergency room two weeks ago with sustained substernal chest tightness. This lasted for 10 hours. EKG and troponin were negative, and it was felt that this was bronchospasm. Subsequently, he has been given Xopenex with temporary improvement in his symptoms, however it recurs return promptly. He is to follow up with his doctor. He evidently underwent pulmonary function tests. The report is not available. He relates there was evidence of early obstruction of airways. His blood pressure control has been good. Lipid status is not known. Additionally, he

R07.9Chest pain, unspecified i11.9 Hypertensive heart disease without h 99214 Office/outpatient Established Mod Md

EMERGENCY DEPARTMENTSEX: MALEAGE: 63DOS: 1/1/20XXCHIEF COMPLAINT: Abdominal pain.HISTORY OF PRESENT ILLNESS: Patient is a male who complains of abdominal pain, developing over the last 3-4 days. Patient states it seems to be in the upper abdominal area. Does not seem to get better or worse with food or with position. He denies any pleuritic nature to the pain. He states it does feel as though it goes straight through toward his back. He states he has been nauseated, but no actual vomiting. He denies any diarrhea, constipation, melena, hematochezia, no ulcer disease, no burning indigestion on a regular basis. Does not take Tums or Rolaids, etc. He denies any gallbladder problems that he is aware of, and he denies any cough, congestion, sputum production. Denies any pulmonary or cardiac symptoms. No radiation up into the neck, jaw, arms, back, or belly. No leg pain or swelling. Patient denies fever, chills.SOCIAL HISTO

R10.13 99284

Emergency Department ReportSex: FAGE: 31DOS: 01/01/20XXTime Seen: 10:43 01/01/20XXArrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESSChief complaint- ABDOMINAL PAIN. This started 3 days ago and is still present. It was gradual in onset. It is not gone now. It is described as pain and it is described as located in the epigastric area. No radiation. At its maximum, severity described as 8 / 10. When seen in the E.D., severity described as 8 / 10. Modifying factors (improved with lying in a ball).The patient has an additional complaint of abdominal pain stinging low pelvic pain.(pt with epigastric pain x 3 days' reports as pressure pain associated with trouble breathing; pt also with low stinging pelvic pain).Similar symptoms previously: Patient has not had similar symptoms previously.Recent medical care: The patient was seen recently by a health care provider. (pt started on Keflex for UTI 2 days

R10.13Epigastric pain R10.2 Pelvic and perineal pain 99284Emergency department visit for the e

Sex: FAGE: 26DOS: 1/1/20XXPHYSICIAN:PREOPERATIVE DIAGNOSIS: Pelvic pain.POSTOPERATIVE DIAGNOSIS: Pelvic pain.OPERATIVE PROCEDURE: Diagnostic laparoscopy.SURGEON:ANESTHESIA: GeneralFINDINGS: Normal pelvis, normal uterus, and normal ovaries and tubes status post tubal ligation, but appear normal as well.ESTIMATED BLOOD LOSS: Less than 10 mL.COMPLICATIONS: None.DESCRIPTION OF PROCEDURE: The patient was taken to the operating room, where general anesthetic was placed without complication. The patient prepped and draped in the normal sterile fashion with legs in the Yellowfin stirrups. A bivalved speculum was placed. The anterior lip of the cervix was grasped with a single tooth tenaculum and the uterine manipulator was placed without difficulty.Attention was turned to the abdomen, where a 5-mm skin incision was made at the umbilicus, through which the 5-mm laparoscope was placed under direct visualization. The abdomen wa

R10.2 Pelvic and perineal pain 49320 1 Laps Abd Prtm&omentum Dx W/wo Spec B

EMERGENCY DEPARTMENTAGE: 23SEX: FEMALEDOS: 1/1//20XXTime Seen: 1156 bed 15. Arrived- By private vehicle. Historian- patient. Note: Previous visits to this facility for other complaints. Patient does not have a primary care physician. HISTORY OF PRESENT ILLNESSChief complaint- ABDOMINAL PAIN. This started several days ago and is still present. It was gradual in onset and has been intermittent and waxing/waning. It is described as "pain" and sharp and it is described as located in the left lower quadrant. At its maximum, severity described as severe. When seen in the E.D., severity described as severe. Modifying factors- worsened by movement. Not relieved by anything. She has had nausea, loss of appetite and vomiting. No diarrhea. Similar symptoms previously: She has had similar symptoms many times previously. These were varying in intensity. Recent medical care: Not recently seen/assessed. REVIEW OF SYSTEMSLast normal

R10.32 Left lower quadrant pain A74.9 Chlamydial infection, unspecified 99284 Emergency department visit for the e

Stacey SmithAGE:25DOS: 01/01/20XXPrivate payer (Medicare rule for 65 or older)CHIEF COMPLAINT: New patient.NP/REF/IRREG PERIODS Q 1-2 MONTHS/ LAST 10-14 DAYS - HEAVY WITH CLOTS/ WAS TOLD HAD OVARIAN CYSTS / LAST US DONE WAS IN 2012 WITH LAST MISCARRIAGEHPI:Long history of irregular menses. May skip 1-2 months then have heavy flow with clots and bad cramps. Not on any medications currently. Has had 4 pregnancies but only one living child, a 2 yo son. Patient does not recall ever having regular cycles.PROBLEMS: Reviewed Problems: Irregular menstrual cycle.ALLERGIES: Reviewed Allergies: PENICILLINS.MEDICATIONS: No medications reported.SOCIAL HISTORY: Reviewed Social History: Alcohol Intake: none. Marital Status: single. Number of Children: 1. Year in School: HS grad. Advance Directive: N.PAST MEDICAL HISTORY: Reviewed Past Medical History: Asthma: Y - as a child/no meds. High Blood Pressure: Y - pre-eclamsia with pregna

R10.32 Left lower quadrant pain N92.6 Irregular menstruation, u 99202 Office/outpatient New Sf Mdm 15-29 M

EMERGENCY DEPARTMENTSex: FAGE: 63DOS: 1/1/20XXCHIEF COMPLAINT: Abdominal pain, onset one week ago, getting better, then escalating for the past 2 days.HISTORY OF PRESENT ILLNESS: This is a female who has the above complaint with nausea and pain around her umbilicus. She states that it also seems to radiate into the right upper quadrant. Food makes no difference for her discomfort. She states that it is better with sitting and worse to moving around. The pain is generally becoming more constant. It is kind of a deep ache. There is slight nausea and some very mild prior diarrhea. There has not been any vomiting. No bloody diarrhea. No dysuria, urgency, frequency. No headache, arthralgia, congestion, back pain, heartburn, chest pain, palpitations, cough, dyspnea, and the rest of her pertinent review of systems for HPI are negative and noncontributory.ALLERGIES: None.MEDICATIONS: Valsartan.PAST MEDICAL HISTORY: GERD.SURG

R10.84 Generalized abdominal pain R11.0 Nausea 99284 Emergency department visit for the e

Emergency Department ReportAge: 56Sex: FemaleDOS: 01/01/20XXPatient arrived by private vehicle with Abdominal generalized pain and nausea and vomiting, she is ambulatory and arrived with a bucket.PAST MEDICAL HX: Depression. Mild bacterial gastritis (ON ABX LAST MONTH). Last normal menstrual period was 3 weeks ago.SURGERY HX: Colonoscopy (LAST MONTH).SOCIAL HX: Occasional alcohol use. Nonsmoker. Functional assessment: no impairments noted. The nutritional risk assessment revealed no deficiencies. No report of abuse. No infectious disease exposure.MEDICATIONS:Birth Control PillsZoloft Oral.Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process. 0224:YJ:CG00060R: (COLL: 01/01/20XX 08:20) ( MsgRcvd 01/01/20XX 08:28) Final resultsLaboratory Test ValueHOLD TUBE FOR COAG SEE NOTE0224:YJ:C00180S: (COLL: 01/01/20XX 08:20) ( MsgRcvd 01/01/20XX 08:49) F

R10.84 Generalized abdominal pain R11.2 Nausea with vomiting, unspecified 99283N/SEmergency department visit for the e

EMERGENCY DEPARTMENTSEX: FemaleAGE: 39DOS:01/1/20XXTime Seen: 00:26 01/01/20XXArrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESSChief complaint- ABDOMINAL PAIN. This started 1 1/2 weeks ago and is still present and worsening. It was gradual in onset. It is not gone now. It is described as pain and it is described as generalized in location. No radiation. At its maximum, severity described as 9 / 10. When seen in the E.D., severity described as 8 / 10. Modifying factors- Not worsened by anything. Not relieved by anything. She has had nausea. The patient has had vomiting (couple times days ago). She has had diarrhea (2 days ago). It has been bloody and watery and contained mucous.No additional abdominal pain.Similar symptoms previously: She has had similar symptoms previously. These were milder.Recent medical care: (last seen by PCP ~3weeks ago).REVIEW OF SYSTEMSThe patient has had constipation

R10.84Generalized abdominal pain E11.65 Type 2 diabetes mellitus with hyperg N83.202Unspecified ovarian cyst, left side Z79.4N/SLong term (current) use of insulin 99285 Emergency department visit for the e

PROCEDURE: ABDOMINAL ULTRASOUNDLocation: OB/Gyn Office (Global) Sex: FemaleAge: 62DOS:1/1/20XXCOMPARISON: None.INDICATIONS: Abdominal pain.TECHNIQUE: High-resolution sonographic examination was performed of the abdomen.FINDINGS:LIVER: Normal.GALLBLADDER: Normal. There is no evidence of cholelithiasis or cholecystitis.BILIARY: Normal. The extrahepatic bile duct measures 3 mm.PANCREAS: The visualized portions of the pancreas are normal.SPLEEN: Normal.KIDNEYS: Normal.AORTA/IVC: Normal.OTHER: Negative.CONCLUSION: Negative abdominal ultrasound. No evidence of cholelithiasis, cholecystitis, or bile duct dilation.Electronically signed by 1/1/20XX

R10.9 Unspecified abdominal pain 76700 Us Abdominal Real Time W/image Docum

RADIOLOGY REPORT Location: AAPC Family Practice Sex: MAGE: 31DATE OF EXAM: 1/01/20XXREFERRED BY PHYSICIAN(S): M.D.PROCEDURE: X-RAY ABDOMEN/KUB SUPINE, ONE VIEWCOMPARISON: None.I NDICATIONS: Abdomen pain. History of stones. TECHNIQUE: A single AP supine view of the abdomen was performed. FINDINGS:BOWEL GAS PATTERN: Normal. CALCIFICATIONS: None significant. OTHER: Normal for age. CONCLUSION: 1. NORMAL EXAM. NO KIDNEY STONES IDENTIFIED. Electronically signed by 1/1/20XX Case ID : OPD7029

R10.9 Unspecified abdominal pain Z87.442 Personal history of urinary calculi 740181 Radiologic Exam Abdomen 1 View

Emergency Department ReportSex: MAGE: 8DOB: 1/1/20xxDOS: 01/01/20XXTime Seen: 09:54Arrived- By private vehicle. Historian- mother.HISTORY OF PRESENT ILLNESSChief Complaint- VOMITING. This started today and is now gone. It was abrupt in onset. The symptoms are described as moderate. He has had a subjective fever (- gone). The patient has had vomiting and decreased oral intake. He has had abdominal pain (- gone). No diarrhea, bloody stools, black stools, flank pain or constipation. No decreased urine output.No recent travel. No known contact with a sick individual, history of possible bad food exposure or change in routine. Has not recently been on antibiotics or camping. (Vomited 6x per mom, then stopped. Now seems fine save for decrease appetite.).Similar symptoms previously: He has had similar symptoms once previously. These were milder. (Last week for one day.).Recent medical care: The patient was seen recently in

R11.10 Vomiting, unspecified 99282 Emergency department visit for the e

SEX: FEMALEAGE: 65DATE: 1/1/20XXADMIT TYPE: OutpatientDigestive Care CenterProcedure: Upper GI endoscopy.Indications: Nausea and vomiting.Referring Physician: Dr. BradshawComplications: No immediate complications.Medicines: Monitored Anesthesia Care. (MAC)Procedure: After obtaining informed consent, the endoscope was passed under direct vision. Throughout the procedure, the patient's blood pressure, pulse, and oxygen saturations were monitored continuously. The endoscope was introduced through the mouth and advanced to the third part of the duodenum. The upper GI endoscopy was accomplished without difficulty. The patient tolerated the procedure well.Findings: The esophagus was normal. A small amount of food (residue) was found in the gastric fundus. The exam of the stomach was otherwise normal. The examined duodenum was normal.Impression: Normal esophagus.A small amount of food (residue) in the stomach.Normal examine

R11.2 Nausea with vomiting, unspecified 43235 Esophagogastroduodenoscopy Transoral

EMERGENCY DEPARTMENTSEX: MALEAGE: 24DOS: 1/1/20XXCHIEF COMPLAINT: Nausea and vomiting.HISTORY OF PRESENT ILLNESS: This is a male with a 5+-year history of intermittent nausea. Patient notes no relieving or inciting factors, says he will sometimes go weeks or months without any nausea and then he may have it daily for a while. Usually does not vomit, although today he did vomit 3 times. He now is completely asymptomatic. Patient never has pain with this, just nausea. No fever, no chills, no frequency, no dysuria, no pain, and no other associated symptoms. Patient says he has been shaky all of his life and continues to be so. He does not feel that his nausea is associated with anxiety.PAST HISTORY: Positive for asthma, which has not bothered him in many years.SOCIAL HISTORY: The patient works at ...Mart. Does not drink alcohol or Smoke, occasionally does drink caffeinated beverages.REVIEW OF SYSTEMS: Negative or noncon

R11.2 Nausea with vomiting, unspecified 99284 Emergency department visit for the e

EMERGENCY DEPARTMENTSEX: FEMALEAGE: 1DOS: 1/1/20XXTime Seen: 17:06 1/1/20XX. Historian- mother and grandmother.HISTORY OF PRESENT ILLNESSChief Complaint- SKIN RASH and TENDER AREA and Complaint (swelling L cheek). This started today and is still present and worsening. It was abrupt in onset and has been constant. Not itchy or painful. It has been located on the left cheek. No cause has been identified. The patient has recently taken medication (2 immun shots each thigh yesterday).Similar symptoms previously: None.Recent medical care: The patient was seen recently in the office (yesterday).REVIEW OF SYSTEMS: No fever, chills, cough, difficulty breathing or hoarseness. No enlarged lymph nodes, diarrhea or vomiting. All systems otherwise negative, except as recorded above.PAST HISTORY: See nurses notes. healthy. Tetanus immunization status is up-to-date.Surgeries: Tympanostomy tube placement (about 1 month ago).Medicati

R22.0 Localized swelling, mass and lump, h 99284 Emergency department visit for the e

RADIOLOGY REPORT LOCATION: AAPC Hospital SEX: FemaleAGE: 72DOS: 1/1/20XXPHYSICIAN(S): M.D.PROCEDURE: CT HEAD WITHOUT CONTRASTINDICATIONS: Altered level of consciousness (Loss of Consciousness LOC) Patient in comaTECHNIQUE: Noncontrast head CT was performed with axial 5 mm reformations.FINDINGS:VENTRICLES: Normal for age.CEREBRUM: Normal for age.CEREBELLUM: Normal for age.BRAINSTEM: Normal for age.BASAL CISTERNS: Normal for age.SKULL: Normal for age.OTHER: Negative.CONCLUSION: Normal non-enhanced head.Electronically signed by 1/1/20XX

R40.20 Unspecified coma 70450 26 CT Scan, Head/Brain; w/o Contrast M

Emergency Department Report - Admitted to ObservationInsurance: Medicare Sex: MAGE: 90Code for OBSERVATIONDOS: 01/01/20XXTime Seen: 11:39 1/1/20XX.Arrived- By ambulance. Historian- EMS personnel and family.HISTORY OF PRESENT ILLNESSChief Complaint- FALL. Location of injuries (Right Shoulder, Hip, Knee). The injury occurred yesterday.Fell (between his bed and wall. Lay there until found this AM by Meals on Wheels.). Occurred at his private homeThe patient complains of mild pain. No blow to the head, neck pain, loss of consciousness or seizure. Not dazed.REVIEW OF SYSTEMSThe patient complains of pain on weight bearing. He cannot bear weight. No numbness, dizziness, loss of vision, hearing loss or chest pain. No difficulty breathing, weakness, headache, nausea or abdominal pain. No laceration, fever, vomiting, urinary problems or depression. All systems otherwise negative, except as recorded above.PAST HISTORYHypertensi

R41.0Disorientation, unspecified S70.01XAContusion of right hip, initial enco S80.01XAN/SContusion of right knee, initial enc F03.90Unspecified dementia without behavio 99223 25 Initial hospital inpatient or observ 93010 Electrocardiogram Report

EMERGENCY DEPARTMENTSEX: FemaleAGE: 92DOS: 1/1/20XXTime Seen: 16:00Arrived- By ambulance. Historian- patient, EMS personnel and family.HISTORY OF PRESENT ILLNESSChief Complaint: DECREASED MENTAL STATUS. slurred speech. This started today and is still present and worsening. It was gradual in onset. (drowsy). Nursing home resident. No history of chronic dementia. Dextro stick was not low prior to arrival. She has had generalized weakness, (no focal weakness). The patient has had a recent fall (last night). No numbness.Usually is alert and oriented X3.Similar symptoms previously: None.Recent medical care: Not recently seen/assessed.REVIEW OF SYSTEMSThe patient sustained a head injury and has had dizziness. No fever, headache, chest pain, difficulty breathing or cough. No sputum production, blurred vision, sore throat, abdominal pain or nausea. No diarrhea, black stools, difficulty with urination, skin rash or joint pain

R41.82 Altered mental status, unspecified E86.0 Dehydration N17.9 Acute kidney failure, unspecified I48.91 Unspecified atrial fibrillation Z79.01 Long term (current) use of anticoagu 99285 Emergency department visit for the e 93010 Electrocardiogram Report 93042 59 Rhythm Ecg 1-3 Leads Interpretation

Emergency Department ReportAGE: 6Sex: MDOS: 01/01/20XXCHIEF COMPLAINT: Fever.HISTORY OF PRESENT ILLNESS: This is a male who comes in today with mom who developed a fever yesterday with associated intermittent raspy breathing, cough as well as a throat pain. Patient's mom states that he has been having generalized body aches and getting a real clear focus of his complaints is difficult. He has been getting Motrin for his symptoms, last given at about 8:00 a.m. this morning. He was seen here last night and diagnosed with a probable viral syndrome. He returns today after mom did not fill the prescription for Tylenol and is concerned that his fevers have not been very well controlled. She was in the area to get the prescription for the Tylenol and thought she would come back by here for recheck. She denies any vomiting or diarrhea. He has been eating and drinking well. He has had some decreased activity but is otherwise

R50.9Fever, unspecified R05.9Cough, unspecified R06.89N/SOther abnormalities of breathing R07.0Pain in throat J45.909N/SUnspecified asthma, uncomplicated Z85.831 Personal history of malignant neopla 99283 Emergency department visit for the e

Emergency Department ReportSex: FAGE: 31DOS: 01/01/20XXTime Seen: 10:44Arrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESSChief Complaint: HEADACHE. This started 3 days ago. It was gradual in onset. It is not gone now. Onset during cannot recall. Is still present. It is described as pain. Described as a global headache and located in the frontal region. No neck pain. Not located in the facial region. At its maximum, severity described as 8 / 10. When seen in the E.D., severity described as 8 / 10. Modifying factors: relieved by nothing. Not worsened by anything. She has had photophobia and nausea. The patient has had vomiting (all day for 3 days). No blurred vision, numbness or weakness.Recent medical care: (pt called Dr. Jones office was referred to ED). Not recently seen/assessed.REVIEW OF SYSTEMSThe patient has had crampy, intermittent abdominal pain (2 weeks). The pain is described as locat

R51.9Headache, unspecified R10.31Right lower quadrant pain R42Dizziness and giddiness R11.2Nausea with vomiting, unspecified Z33.1Pregnant state, incidental 99285 Emergency department visit for the e

EMERGENCY DEPARTMENTSEX: FemaleAGE: 97DOS: 1/1/20XXCHIEF COMPLAINT: Low blood pressure per Skyler staff.HISTORY OF PRESENT ILLNESS: This is a female who was brought here from Skyler because she was thought to have a low blood pressure and hypothermia. She herself has had no complaints. She is in declining health, having been moved from her home to Skyler 3 weeks ago. She has had physical and mental deterioration over the past month or so. She is in the process of being moved into the enhanced care unit at Skyler and there was discussion about having hospice begin providing care for her. The patient's son came to provide more information as the patient is not able to answer questions with reliability.PAST MEDICAL HISTORY: Significant for hypertension, arthritis, anxiety, hypothyroidism, incontinence, frequent UTIs.MEDICATIONS:Valium.Aspirin.Potassium.Nexium.Diovan.Lasix.Armour Thyroid.ALLERGIES: KEFLEX AND TAPE.SOCIAL

R53.1 Weakness E86.0 Dehydration E87.1 Hypo-osmolality and hyponatremia 99284 Emergency department visit for the e

EMERGENCY DEPARTMENTSEX: MALEAGE: 60DOS: 1/1/20XXCode only for the ER physicianArrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS:Chief Complaint- MULTIPLE SYNCOPAL EPISODES. It has been waxing/waning. This occurred over past few weeks, 3 times this week. He has recovered. Is no longer unconscious. Event was witnessed. At time of event, he was standing. He had preceding symptoms of light-headedness. No preceding symptoms of nausea, dim vision, chest pain, warmth or abdominal pain. He lost consciousness completely. No seizure activity, incontinence or apnea noted. Did not lose pulse. Experienced repeated episodes. The episode lasted seconds. No injuries noted. The patient currently has generalized weakness. No localized weakness. Similar symptoms previously: He has had similar symptoms previously. Recent medical care: The patient was seen recently by a health care provider. REVIEW OF SYSTEMS:T

R55 Syncope and collaps 99285 25 Emergency department visit for the e 93010 Electrocardiogram Report 93042 59 Rhythm Ecg 1-3 Leads Interpretation

OFFICE PROCEDURECARDIOLOGYSEX: MALEAGE: 66Transthoracic Echocardiography ReportComplete 2D Study with M-Mode, Complete Spectral Doppler, and Color Doppler01/01/20XXMR#Account: Status: InpatientLocation: Tape: Ht 72 in (182.9 cm)Wt 200 lb (90.9 kg)BSA 2.13 m squaredDiagnoses: SYNCOPE COLLAPSEEcho Attending: Echo Technologist: Attending Ordering: SummaryLeft ventricle: Systolic function was normal by visual assessment. Ejection fraction was estimated to be 60% in the range of 55% to 65%. Although no diagnostic regional wall motion abnormality was identified, this possibility cannot be completely excluded on the basis of this study. Doppler parameters were consistent with abnormal left ventricular relaxation (grade 1 diastolic dysfunction). COMPARISONS: No previous study is available for comparison. INDICATIONS: Syncope. HISTORY: Syncope. Change in mental status. PRIOR HISTORY: Risk factors: Oral hypoglycemic-treated di

R55 Syncope and collapse 933061 26 Echo Tthrc R-t 2d W/wom-mode Compl S

AGE: 77Sex: FemaleDOS 01/01/20XXArrived- By ambulance. Historian- patient, EMS personnel and son. Note: Previous visits to this facility for similar complaints.HISTORY OF PRESENT ILLNESSChief Complaint- SINGLE SYNCOPAL EPISODE. It was abrupt in onset and has been constant. This occurred just prior to arrival. She has recovered. Event was witnessed. At time of event, she was standing (for brief time). She had preceding symptoms of light-headedness and nausea. No preceding symptoms of chest pain. She felt faint, lost consciousness, was apneic and collapsed. The patient was incontinent of feces. No seizure activity. Had a single episode. The episode was brief. The episode lasted seconds. No injuries noted. The patient currently has weakness. Currently has nausea. No headache currently.Similar symptoms previously: She has had similar symptoms several times previously.Recent medical care: The patient was seen recently at

R55Syncope and collapse E86.0Dehydration N28.9N/SDisorder of kidney and ureter, unspe D64.9Anemia, unspecified 99284 25 Emergency department visit for the e 93010 Electrocardiogram Report 93042 59 Rhythm Ecg 1-3 Leads Interpretation

OPERATIVE REPORTSEX: FemaleAGE: 58This payer requires RT and LT ModifiersDATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Right axillary enlarged lymph nodePOSTOPERATIVE DIAGNOSIS: Right axillary enlarged lymph nodePROCEDURE PERFORMED: Excision of deep right axillary enlarged lymph node.ANESTHESIA: General.SKIN PREP: ChloraPrep.DRAINS: None.INDICATIONS: This patient has a history of prior non-Hodgkin's lymphoma. She developed a right axillary enlarged node.DESCRIPTION OF PROCEDURE: The patient was anesthetized, prepped and draped and a transverse low axillary incision was made and carried down sharply to the mass which was an enlarged lymph node. It was excised using sharp dissection and submitted for pathologic evaluation. I spoke with the pathologist regarding the node and the history of lymphoma and it will be processed accordingly. Closure was with 2-0 Vicryl subcutaneous closure and a

R59.0 Localized enlarged lymph nodes Z85.72 Personal history of non-Hodgkin lymp 38525 1 RT Bx/exc Lymph Node Open Deep Axillary

PROGRESS NOTEAGE: 82Attending Physician:Referring Physician:Date: 01/01/20XXCHIEF COMPLAINT: Today he is here for six-month check and echocardiogram results.PROBLEM LIST1. 82-year-old with history of early constrictive pericarditis, secondary to acute pericarditis, treated with prednisone.2. History of progressive increase in white cell count increasing from pericardial effusion and thickening secondary to recent pericarditis; so far refractory to steroid therapy with left heart catheterization showing normal coronary arteriogram and left ventriculogram. Findings consistent with constrictive pericarditis.3. Normal coronary arteriogram (0X/20XX).4. Pulmonary infiltrates settling on recent CT scan.5. S/P left anterior descending and diagonal branch stenting (20XX) with residual diffuse circumflex disease.6. Mild to moderate ischemic cardiomyopathy, ejection fraction initially 40%, now 65%.7. 13+ year history of hyperte

R60.0 I11.9 99214

EMERGENCY DEPARTMENTSEX: FemaleAGE: 1DOS: 1/1/20XXTime Seen: 9:27 bed 25.Arrived- By private vehicle. Historian- mother and father. Note: Patient has a primary care physician on staff; PCP has been notified.HISTORY OF PRESENT ILLNESSChief Complaint- FUSSY and WON'T STOP CRYING. This started about 3 days ago and is still present. It has been intermittent. Symptoms are described as severe. No fever, ear pain or eye irritation or eye discharge. No nasal discharge or congestion, sore throat, cough or difficulty breathing. No vomiting, diarrhea, bloody stools, abdominal pain or ear-pulling. No headache, seizure, difficulty with urination, skin rash or diaper rash. Has not had decreased oral intake or been acting differently. No decreased urine output. No history of substance ingestion. (This delightful 2 month old got her shots 2 days ago. That night, and the 2 intervening, she began crying about 8, and wouldn't stop for

R68.12 fussy infant (baby) 99282 Emergency department visit for the e

EMERGENCY DEPARTMENTSEX: FemaleAGE: 80DOS: 1/1/20XXTime Seen: 1728. Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS: Chief Complaint: ABNORMAL INR (13). This started today and is still present (Had blood drawn this am). (Wears NC O2, has had intermittent nose bleeds for the last week.Was recently treated for thrush with Diflucan for 1 week. This ended 1 week ago.Last had her INR checked 2 weeks ago and normal.). Recent medical care: The patient was seen recently in the office.REVIEW OF SYSTEMSNo fever, sore throat, sinus drainage, cough or difficulty breathing. No chest pain, abdominal pain, nausea, vomiting or diarrhea. No difficulty with urination, skin rash or back pain. All systems otherwise negative, except as recorded above. PAST HISTORYAtrial fibrillation. Coronary artery disease. Prior coronary artery bypass graft surgery. Congestive heart failure. Hyperlipidemia. Arthritis. Anxiet

R79.1 R00.0 T37.8XA 99284

DATE: 11/21/20xxSEX: FEMALEAGE: 39HISTORY: She came in for a colposcopy and ECC due to an abnormal pap smear with LGSIL. Procedure was explained to patient. Questions were answered. Urine pregnancy test done, results negative.COLPOSCOPY: Patient was put in lithotomy position and speculum was inserted. At the time that we did the ECC and did the colposcopy via Gynecor making sure that we got good diagnostic tissue. Specimen obtained at 12-1 o'clock and at 1-4 o'clock. After the procedure was terminated no bleeding was noted. Patient was sent home.PLAN: Patient to call back in 7-10 days for results.signed______________Dr. Kramer

R87.612 Z32.02 57454 81025

OPERATIVE REPORTSex: FAGE: 54DOS: 1/1/20XXSURGEON: Frederic KramerANESTHESIOLOGIST:ANESTHESIA: General endotracheal anesthesia.PREOPERATIVE DIAGNOSIS: Right upper lobe nodule suspicious for cancer.POSTOPERATIVE DIAGNOSIS: Right upper lobe nodule suspicious for cancer.TITLE OF OPERATION: Fiberoptic bronchoscopy and discontinuance of planned pulmonary resection.INDICATIONS: This patient had undergone a left upper lobectomy following high dose radiation and concurrent chemotherapy for a Pancoast tumor. She subsequently on follow up has presented with a small nodule in the apex of the right lung which is enlarging and is suspicious for a metachronous primary lung cancer. She was being anesthetized with the intent of performing a right apical anatomic segmentectomy.PROCEDURE: Under satisfactory general anesthesia, an Olympic fiberoptic bronchoscope was advanced down the endotracheal tube. The right-sided anatomy was perfe

R91.1 Z85.118 Z90.2 Z92.3 Z92.21 31622

EMERGENCY DEPARTMENTSEX: FemaleAGE: 31DOS: 1/1/20XXTime Seen: 23:11; initial patient contact. Arrived- By ambulance. Historian- patient. HISTORY OF PRESENT ILLNESS:Chief Complaint- REPORTED PHYSICAL ASSAULT. Location of injuries- face, chest and left shoulder. This occurred just prior to arrival. Reported assailant: family relative. The patient sustained a blow. Occurred at home. The patient complains of moderate pain. The patient sustained a blow to the head and was dazed. No loss of consciousness or alcohol consumed. REVIEW OF SYSTEMS:No rectal pain / discomfort. The patient has had chest pain (L chest wall). No numbness, dizziness, headache, nausea or abdominal pain. No vaginal pain, depression, vomiting, urinary problems or vaginal bleeding. No loss of vision (Left eye blurry). All systems otherwise negative, except as recorded above. PAST HISTORY: See nurses notes. Additional Problems: no known problems. Additio

S00.83XA S20.212A Y04.0XXA Y92.009 Y07.499 99284

Location: AAPC Urgent Care Clinic (report global fee) Sex: MaleAge: 74DATE OF EXAM: 1/1/20XXPHYSICIAN(S):PROCEDURE: CT HEAD WITHOUT CONTRASTCOMPARISON: None.INDICATIONS: Status-post fall with loss of consciousness.TECHNIQUE: Noncontrast head CT was performed with axial 5 mm reformations.FINDINGS: There is a small extra-axial fluid collection on the right side. It overlies the right parietal hemisphere. It is moderately dense. The pattern suggests a small subdural hematoma. It is perhaps 7-8 mm in greatest thickness. There is effacement of the sulcal markings in the right parietal lobe. The ventricles are still in the midline. No signs of any intraaxial hemorrhage. At the base of the brain, the cisterns are still open. On the bone window settings, no definite skull fracture is seen on that side.CONCLUSION:1. SMALL RIGHT SIDED SUBDURAL HEMATOMA WITH MILD MASS EFFECT.

S06.5X9A Traumatic subdural hemorrhage with l 70450 CT Scan, Head/Brain; w/o Contrast Ma

EMERGENCY DEPARTMENT Report External Cause CodesSex: MAGE: 39DOS: 1/1/20XXArrived- By ambulance. Historian- patient and EMS personnel.HISTORY OF PRESENT ILLNESS:Chief Complaint- MOTOR VEHICLE COLLISION. Location of injuries- chest, abdomen, and left knee.The patient complains of mild pain. No blow to the head, neck pain, loss of consciousness or seizure. Not dazed.Mechanism details- Patient was driving the vehicle and was wearing a lap belt and shoulder harness. Patient's vehicle was a sedan and the other vehicle involved was a van. Impact was on the front of the vehicle. The air bag deployed. The accident involved two vehicles and a moderate impact velocity and resulted in mild damage to the patient's vehicle. Estimated speed of the collision: 20 - 30 mph. The vehicle did not overturn. The patient was not ejected from the vehicle. The windshield was not starred. The steering wheel was not broken. There was not a pro

S20.219A S80.02XA V43.54XA 99285 25 93010

EMERGENCY DEPARTMENTSEX: FEMALEAGE: 39DOS: 01/01/20XXTime Seen: 09:27 01/01/20XXArrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESSChief Complaint: BACK PAIN. Onset- 3 days ago working in the garden of single family (private) residence and it is still present. It was gradual in onset and has been constant. It is described as being severe and in the left interscapular area, area of the left side of the mid-thoracic spine and right side of the mid-thoracic spine and right interscapular area. The quality is noted to be aching and pain. No radiation. Modifying factors- worsened by rotation of the body or bending over. Relieved by remaining still.Associated symptoms - No bladder dysfunction, bowel dysfunction, sensory loss or motor loss.Patient notes an injury. Mechanism of injury (doing chores at home). Patient denies injury to the head or chest. No other injury.Similar symptoms previously: She has

S29.012A Strain of muscle and tendon of back Y92.017 Garden or yard in single-family Y93.H2N/SActivity, gardening and landscaping 99284 Emergency department visit for the e

OPERATIVE REPORTAge: 33SEX: MALEDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: GUNSHOT WOUND TO THE RIGHT LOWER QUADRANT.PROCEDURES: EXPLORATORY LAPAROTOMY, REMOVAL OF TERMINAL ILEUM AND CECUM, ILEOCOLOSTOMY AND PRIMARY ANASTOMOSIS.POSTOPERATIVE DIAGNOSIS: THRU AND THRU GSW PERFORATION OF THE CECUM.SURGEON:ANESTHESIA: GENERAL, ENDOTRACHEAL.ESTIMATE BLOOD LOSS: ABOUT 100 CC.WOUND CLASS: CONTAMINATED.FINDINGS: Perforation of cecum. No gross fecal contamination. No retroperitoneal hematoma. No bowel staining, good blood flow via the arcades to the anastomosis.INDICATIONS: The patient is a man who was walking on the street and was shot in the right lower abdominal quadrant. A 1.5 cm injury site was found in the right lower quadrant with no active bleeding wound. The patient was presented and was taken to the trauma bay and evaluated. The patient was noted to have peritoneal signs and emergently taken to the operating

S31.643A Puncture wound with foreign body of 44160 Colectomy Prtl W/rmvl Terminal Ileum

OPERATIVE REPORTSEX: FEMALEAGE: 46DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: L2 WEDGE COMPRESSION FRACTURE.PROCEDURES: L2 VERTEBROPLASTY.POSTOPERATIVE DIAGNOSIS: L2 WEDGE COMPRESSION FRACTURE.SURGEON: Christian Jones, MDANESTHESIA: GENERAL.ESTIMATED BLOOD LOSS: TWO TO THREE DROPS.COMPLICATIONS: NONE.INDICATIONS: The patient is a middle-aged woman who several days prior suffered a fall which she felt was a compression fracture of the L2 vertebral body. The patient was neurologically un-compromised. She was complaining severe pain due to the fracture and because of the presence of angulation in the fracture, my recommendation was to perform a vertebroplasty. The procedure along with its risks, possible benefits and possible complications were explained to the patient to her understanding. Surgical and nonsurgical alternatives were discussed with her and her questions were answered to her satisfaction. She conse

S32.020A Wedge compression fracture of second 22511 1 Perq Vertebroplasty Uni/Bi Injection

OPERATIVE REPORTSEX: MaleAGE: 23DATE OF OPERATION: 01/01/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Blunt abdominal trauma with small-bowel perforation.POSTOPERATIVE DIAGNOSIS: Blunt abdominal trauma with small-bowel perforation.PROCEDURE PERFORMED: Exploratory laparotomy and repair of small-bowel perforation.ANESTHESIA: General.SKIN PREP: ChloraPrep.DRAINS: None.INDICATIONS: Blunt abdominal trauma with seatbelt injury and abdominal tenderness with guarding and CT scan suggesting extraluminal gas.FINDINGS: Mid jejunal perforation. No other significant injuries were identified.DESCRIPTION OF PROCEDURE: The patient was anesthetized, prepped and draped, and a vertical midline incision was made. Succus entericus was present and was suctioned out. The small bowel was followed from the ligament of Treitz to the ileocecal valve and a single perforation was identified and was closed with a TA60 stapler. The colon

S36.438A 44602

EMERGENCY DEPARTMENTSEX: FEMALEAGE: 47DOS: 1/1/20XXThis is a Commercial Payer (Follow Medicare rules for 65 and older) ALSO report external causes) Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS:Chief Complaint: BACK PAIN. Onset was last night and it is still present. It was abrupt in onset. It is described as being moderate in degree and in the area of the right lower lumbar spine. The quality is noted to be "pain" and similar to prior episodes. No radiation. Modifying factors- worsened by rotation of the body or bending over. Associated symptoms - No bladder dysfunction, bowel dysfunction, sensory loss or motor loss. Patient notes an injury. Mechanism of injury- she was lifting a heavy tote at work. Patient denies injury to the head or neck. No other injury. Similar symptoms previously: She has had similar symptoms previously. Recent medical care: Not recently seen/assessed. REVIEW OF S

S39.012A K43.9 X50.0XXA Y92.89 Y99.0 99284

Emergency Department ReportSex: MAGE: 61DOS: 01/01/20XXCHIEF COMPLAINT: Left hip pain.HISTORY OF PRESENT ILLNESS: This is a male who had been jogging ,on residential street, today and after jogging felt as if he had some pain just superior to his left hip. He did not have any injury. The onset was gradual. He denies any abdominal pain, nausea or vomiting. He denies diarrhea or constipation. He denies any hematochezia or melena. He denies any other acute complaints. He does have some complaints of some chronic pains in his joints when he uses them more. He is right-handed and complains of some right elbow pain when he is mopping and doing his usual activities. This has not been occurring currently or even in the last few days but does occasionally bother him.PAST MEDICAL HISTORY: Denies.MEDICATIONS: DeniesALLERGIES: NO KNOWN DRUG ALLERGIES.SOCIAL HISTORY: The patient denies tobacco, alcohol or drugs. He works as a hou

S39.013A Strain of muscle, fascia and tendon M77.11 Lateral epicondylitis, right elbow 99282 Emergency department visit for the e

Emergency Department Report Insurance: MedicareSex: FAGE: 93DOS: 01/01/20XXTime Seen: 05:08Arrived- By ambulance. Historian- patient and EMS personnel.HISTORY OF PRESENT ILLNESSChief Complaint- FALL. Location of injuries- head and right shoulder. The injury occurred just prior to arrival.Tripped and fell in the hallway. Occurred at her private residential home.The patient complains of severe pain. The patient sustained a blow to the head. No neck pain, loss of consciousness or seizure. Not dazed.REVIEW OF SYSTEMS: The patient sustained skin laceration to the face. No numbness, dizziness, loss of vision, hearing loss or chest pain. No difficulty breathing, weakness, headache, nausea or vomiting. All systems otherwise negative, except as recorded above.PAST HISTORY: Risk factors for neck injury- age over 40. Denies the following risk factors for neck injury - history of ankylosing spondylitis, severe osteoarthritis and

S43.014A Anterior dislocation of right humeru S01.111A Laceration without foreign body of r N39.0Urinary tract infection, site not sp 99284 57 Emergency department visit for the 23650 RT Clsd Tx Shoulder Dislc W/manipulatio 12011 XS,RT Simple Repair F/e/e/n/l/m 2.5cm/< 71045 26 Radiologic Exam Chest Single View

VALLEY RADIOLOGY (Global Billing) PROCEDURE: MRI RIGHT SHOULDER WITHOUT CONTRAST COMPARISON: None. INDICATIONS: Right shoulder pain with decreased range of motion. History of dislocation.TECHNIQUE: Axial T2 GRE; oblique coronal TSE PD fat sat, TSE T2 fat sat, T1 weighted; oblique sagittal T1, and TSE PD fat sat sequences.FINDINGS:ROTATOR CUFF: There is a laminated interstitial tear at the conjoined distal supraspinatus/ infraspinatus tendon. No full-thickness rotator cuff tear is present.MUSCLES: Normal in signal and volume. No fatty infiltration, edema, or atrophy.LIGAMENTS: The glenohumeral ligaments are intact. The coracoclavicular, coracoacromial, and coracohumeral ligaments are intact.LABRUM: There is a detached but nondisplaced tear of the posterior labrum. The superior, anterior, and inferior labra are intact.AC JOINT: Normal. No osteoarthritic changes are present. No AC joint effusion or separation noted.ACRO

S43.491A 73221 RT

Emergency Department ReportAGE: 32Sex: MDOS: 01/01/20XXCHIEF COMPLAINT: Left arm pain.HPI: This is a male man who fell on his left arm. This happened about 2 hours ago. He was playing with his kids, at his single family private home, and tripped over one of them and fell. He has some numbness in his fingers at baseline due to a history of frostbite. However, he has no new paresthesias. He did not take any medication for it. He denies any other trauma including head trauma. He denies loss of consciousness.PAST MEDICAL HISTORY: Irritable bowel syndrome.PAST SURGICAL HISTORY: Hernia repair.MEDICATIONS: None.ALLERGIES: PENICILLIN.SOCIAL HISTORY: The patient does not smoke or drink alcohol. He denies any other drugs.REVIEW OF SYSTEMS: As per the HPI, otherwise unremarkable.PHYSICAL EXAM: VITAL SIGNS: Temperature 98.6, pulse 103, respiratory rate 16, pulse oximetry 96% on room air, blood pressure 138/82. GENERAL: He is a w

S50.812A Abrasion of left forearm, initial en S50.12XA Contusion of left forearm, initial e W03.XXXA Other fall on same level due to coll Y92.019 Unspecified place in single-family 99283 Emergency department visit for the e

OFFICE - ESTABLISHED (Bill Global for Radiology)Dr. John JonesSEX: MaleAGE: 27DOS: 1/1/20XXFollow Up Exam: Re: Jonathan CampbellJonathan Campbell is doing well and is having no problems. He does have some pain and redness at the end of the day, but states that it is slowly improving. X-rays taken today in our office in two views show that his right hand fractured 3rd metacarpal is completely healed. His right hand fractured 2nd metacarpal shows a very small area of nonunion, but overall appears to be structurally stable. We will let him return to work with no restrictions. We will see the patient back in 3 months, sooner if there are any problems. ASSESSMENT: Right Hand - Non Union Fractured 2rd MetacarpalSincerely,John Jones, MDElectronically signed by JOHN JONES, MD 1/1/20XX​

S62.300K 99212 25 73120 RT

Age: 16Sex: FemaleDate of Service: 1/1/20XXService Department: Orthopedic Group GeneralPREOPERATIVE DIAGNOSIS: Left fifth metacarpal base fracture.POSTOPERATIVE DIAGNOSIS: Left fifth metacarpal base fracture.NAME OF PROCEDURE:1. Closed reduction pin fixation of the left fifth metacarpal base fracture.2. Intraoperative use of fluoroscopy.SURGEON:INDICATIONS: The patient is a female who presents with a displaced left fifth base metacarpal fracture.DESCRIPTION OF PROCEDURE: The patient was taken to the operating room where she was first given axillary block anesthesia. Next her forearm and hand were prepped and draped in the normal sterile circumferential fashion. Next her arm was exsanguinated, tourniquet inflated 250 mmHg. Next, I manipulated the fracture and was able to get satisfactory reduction. I then placed one 0.62 K-wire across the fracture site through the joint. I used the image intensifier to assess the redu

S62.317A 26608 LT

OFFICE VISIT SEX: MALEAge: 16DATE OF SERVICE: 1/1/20XXSUBJECTIVE: This 16-year-old boy injured his left ring finger this afternoon at high school when a door was slammed on it by another careless student. He has suffered a traumatic partial avulsion of his nail with lacerations to the distal phalanx but no apparent injury to the DIP joint. He was initially evaluated in the office at the home for definitive evaluation and treatment. He is accompanied by his host at the home, Sam, for the initial part of the evaluation and then for the remainder of the exam and treatment is accompanied by Julie, RN.PHYSICAL EXAMINATION: The patient is ambulatory on arrival and when the gauze dressing was removed there was some moderate bleeding and oozing. He has surprisingly minimal pain. Distal neurovascular function intact. A digital block was performed by injecting 1 mL of 2% lidocaine without epinephrine into the flexor sheath on

S67.195A W23.0XXA Y92.213 99213 25 11730 F3 73120 52 LT

EMERGENCY DEPARTMENTSEX: FEMALEAGE: 74DOS: 1/1//20XXTime Seen: 03:15Arrived- By ambulance. Historian- patient and EMS personnel. Note (Dr Derek Jones).HISTORY OF PRESENT ILLNESS: Chief Complaint- FALL. Location of injuries- right hip. The injury occurred just prior to arrival. Fell while in bathroom on toilet striking the floor (wasn't using her walker). Occurred at Single private family residence (home).The patient complains of moderate pain. No blow to the head, neck pain or loss of consciousness.REVIEW OF SYSTEMS: No numbness, dizziness, loss of vision, hearing loss or chest pain. No difficulty breathing, weakness, headache, nausea or abdominal pain. No vomiting. All systems otherwise negative, except as recorded above.PAST HISTORY: Asthma. Hyperlipidemia.Risk factors for neck injury- age over 40. Denies the following risk factors for neck injury - history of ankylosing spondylitis, severe osteoarthritis and prior

S72.141A Displaced intertrochanteric fracture W18.11XA Fall from or off toilet without subs Y92.012 Bathroom of single-family (private) 99285 Emergency department visit for the e 93010 Electrocardiogram Report

OPERATIVE REPORTSEX: MALEAGE: 17DATE: 01/01/20XXPREOPERATIVE DIAGNOSIS:1. Left basicervical femoral neck fracture.2. Comminuted right subtrochanteric femur fracture.POSTOPERATIVE DIAGNOSIS:1. Left basicervical femoral neck fracture.2. Comminuted right subtrochanteric femur fracture.OPERATION:1. Open reduction and internal fixation of left basicervical femoral neck fracture using cannulated-screw fixation.2. Intramedullary stabilization of comminuted right subtrochanteric femoral shaft fracture using locked trochanteric entry nail3. Intraoperative fluoroscopy Surgeon: Christopher Thomas, M.D.1st Assistant: Nathan Jones, M.D.Anesthesia: General.HISTORY: The patient is a 17-year-old male who was involved in a motor vehicle accident. He was a passenger in a truck that drove off the state road and struck a tree going at a fairly high rate of speed. His brother was the driver and was also injured. Kris sustained, among oth

S72.21XA Displaced subtrochanteric fracture oDetail S72.042ADisplaced fracture of base of neck oDetails 27245 RT Tx Inter/pr/subtrchntric Fem Fx 27236 59,LTOptx Fem Fx Prox End Nck Int Fixj/pr

SEX: MALEAge: 62DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: RIGHT LOWER END TIBIA STATUS POST ORIF WITH RETAINED SYNDESMOTIC SCREW, LEFT LOWER END TIBIA STATUS POST EXTERNAL FIXATION WITH RETAINED HARDWARE.PROCEDURES: RIGHT LOWER END TIBIA REMOVAL OF SYNDESMOTIC SCREWS, LEFT LOWER END TIBIA REMOVAL OF EXTERNAL FIXATOR.POSTOPERATIVE DIAGNOSIS: RIGHT LOWER END TIBIA STATUS POST ORIF WITH RETAINED SYNDESMOTIC SCREW AND LEFT LOWER END TIBIA STATUS POST EXTERNAL FIXATION WITH RETAINED HARDWARE.SURGEON:ANESTHESIA: LOCAL WITH IV SEDATION. (MAC)ESTIMATE BLOOD LOSS: 20 CC.TOURNIQUET TIME: NONE.ANTIBIOTICS: 1 GM OF ANCEF.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who sustained a left lower end tibia fracture and had external fixation and a right lower end tibia ORIF with syndesmotic screws. He had healed the syndesmotic area and was complaining of the external fixator and requesting removal.Options, risks an

S82.301D S82.302D Z47.89 20680 RT 20694 LT

Sex: FAGE:48DATE OF OPERATION: 1/01/20XXPREOPERATIVE DIAGNOSIS: DISPLACED RIGHT LATERAL MALLEOUS (DISTAL FIBULA) AND RIGHT ANKLE WITH MORTISE INSTABILITYPROCEDURES: OPEN REDUCTION AND INTERNAL FIXATION RIGHT ANKLE; LATERAL APPROACH.1. SEVEN-HOLE SEMITUBULAR PLATE.2. TIMES 4 FULL THREADED CORTICAL SCREWS.3. TIMES 2 FULL THREADED CANCELLOUS SCREWS.4. POSTERIOR SPLINT AND MOBILIZATION.5. TOURNIQUETPNEUMATIC.6. IMAGE INTENSIFIER CONTROL.POSTOPERATIVE DIAGNOSIS: DISPLACED RIGHT LATERAL MALLEOUS (DISTAL FIBULA) AND RIGHT ANKLE WITH MORTISE INSTABILITYSURGEON: Jackson Thomas, M.D.ANESTHESIA: GENERAL.ANESTHESIOLOGIST: Lizzie Thompson, M.D.PROCEDURE: After adequate induction with general anesthesia and the patient in the supine position, a pneumatic tourniquet was applied to the high right thigh region and not inflated. A soft bump was placed posterior to the right hip to control rotation of the right lower extremity. The rig

S82.61XA Displaced fracture of lateral malleo M25.371 Other instability, right ankle 27792 RT Open Tx Distal Fibular Fracture Lat

SEX: MALEAGE: 26DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: DISPLACED LEFT ANKLE BIMALLEOLAR EQUIVALENT FRACTURE.PROCEDURES: LEFT ANKLE ORIF, LATERAL MALLEOLUS.POSTOPERATIVE DIAGNOSIS: LEFT ANKLE DISPLACED FRACTURE OF LATERAL MALLEOLUS OF LEFT FIBULA WITH DISRUPTION OF SYNDEMOSISSURGEON:ANESTHESIA: GENERAL, ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 25 CC.TOURNIQUET TIME: NONE.ANTIBIOTICS: 1 GM ANCEF PREOP AND 1 GM ANCEF POSTOP.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who was rollerblading and sustained an injury to the left ankle, which was bimalleolar equivalent with fracture dislocation. This was closed reduced in the emergency room but was unstable. Options, risks and benefits were discussed with the patient and he agreed with the open reduction internal fixation.PROCEDURE: The patient was brought to the operating room and anesthesia was induced via the endotracheal tube. The left lower extremity

S82.62XA Displaced fracture of lateral malleo Y93.51 Activity, roller skating (inline) an 27792 LT Open Tx Distal Fibular Fracture Lat

EMERGENCY DEPARTMENTAge 26Sex: MDOS: 1/1/20XXCHIEF COMPLAINT: Left ankle pain.HPI: This is a male who was playing football when another player landed on his left ankle and he fell to the ground. He heard a pop and saw his leg deformed. He denies any other injuries and was wearing a helmet. He otherwise feels well. He comes in with a splint on his leg, but no pain medication prior to arrival.PAST MEDICAL HISTORY: Denies.MEDICATIONS: Denies.ALLERGIES: NO KNOWN DRUG ALLERGIES.SOCIAL HISTORY: The patient does not smoke or drink alcohol.REVIEW OF SYSTEMS: As per the HPI, otherwise unremarkable. He specifically also does not have any distal paresthesias, though he does have some numbness about the ankle.PHYSICAL EXAM: VITAL SIGNS: Temperature 99.4, pulse 76, respiratory rate 16, pulse oximetry 100%, blood pressure 126/75.GENERAL: He is a well-developed, well-nourished, pleasant young man appearing his stated age and appear

S82.842A Displaced bimalleolar fracture of le S93.05XA Dislocation of left ankle joint, ini 99284 57 Emergency department visit for the e 27840 LT Closed Tx Ankle Dislocation W/o Anes 99152 Mod Sed Same Phys/qhp Initial 15 Min

OPERATIVE NOTESEX: FemaleAGE: 62DOS: 1/1/20XXPHYSICIAN: Winston Jones, MDPREOPERATIVE DIAGNOSIS: Right knee medial meniscal tear.POSTOPERATIVE DIAGNOSIS: Right knee medial and lateral meniscal tear and chondromalacia, plicaOPERATIVE PROCEDURE: Right knee arthroscopy, partial medial meniscectomy, synovectomy, and chondroplasty.SURGEON: Winston Jones, MDANESTHESIA: General.COMPLICATIONS: None.CONDITION: Stable to recovery room.FINDINGS: Grade 4 changes of the medial femoral condyle and medial tibial condyle, and lateral tibia, large middle and post one-third medial meniscal tear, and a medial plica.INDICATIONS: Patient is a female with severe pain in her right knee that was quite acute with nature due to degenerative changes. It was consistent with a meniscal tear and it was recommended that she undergo a right knee arthroscopy and debridement as she felt she had failed conservative treatment. The risks and benefits we

S83.241A Other tear of medial meniscus, curre S83.281A Other tear of lateral meniscus, curr M94.26 1Chondromalacia, right knee M67.51 Plica syndrome, right knee 29881 RT Arthrs Kne Surg W/Meniscectomy Med/L

OPERATIVE REPORTSEX: MaleAGE: 34DATE OF OPERATION: 01/01/20XXPREOPERATIVE DIAGNOSIS: RIGHT KNEE TORN ANTERIOR CRUCIATE LIGAMENT, TORN MEDIAL MENISCUS.PROCEDURES: RIGHT KNEE ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION WITH ACHILLES TENDON ALLOGRAFT ALL SOFT TISSUE AND PARTIAL MEDIAL MENISCECTOMY.POSTOPERATIVE DIAGNOSIS: RIGHT KNEE TORN ANTERIOR CRUCIATE LIGAMENT, TORN MEDIAL MENISCUS.SURGEON: M.D.ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 10 CC.TOURNIQUET TIME: 83 MINUTES.ANTIBIOTICS: ANCEF 1 GM PREOP, ANCEF 1 GM POSTOP.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who sustained an injury to the right knee six months ago, who was complaining of instability and pain. He was found on physical exam to have instability with the positive Lachman, positive Pivot shift. On MRI, he was found to have torn ACL and a probable torn medial meniscus. Options, risks and benefits were discussed with the pat

S83.511A Sprain of anterior cruciate ligament S83.241A Other tear of medial meniscus, curre 298881 RT Arthrs Aided Ant Cruciate Ligm Rpr/a 29881 RT Arthrs Kne Surg W/Meniscectomy Med/L

Sex: FAGE: 24DOS: 1/1/20XXPHYSICIAN: R Jones, MDPREOPERATIVE DIAGNOSIS: Metaphyseal diaphyseal (Jones Fracture), right foot fifth metatarsalPOSTOPERATIVE DIAGNOSIS: Metaphyseal diaphyseal (Jones Fracture), right foot fifth metatarsalOPERATIVE PROCEDURE: Open reduction internal fixation, right foot fifth metatarsal Jones fracture.FLUOROSCOPY - C-armSURGEON: R Jones, MDASSISTANT: Scott Andrews, PAANESTHESIA: General endotracheal anesthetic administered by Dr. Varsha Menon.ESTIMATED BLOOD LOSS: Minimal.COMPLICATIONS: None.INDICATIONS: The patient is a female who has, fractured her right foot fifth metatarsal, from a fall on same level(Sidewalk) due to ice, while running two days ago. She has been non weightbearing and compliant with her conservative approach. Unfortunately, however, her fracture has not healed and is not demonstrating evidence of healing. Felt appropriate to go ahead with surgical intervention in the fo

S92.351A Displaced fracture of fifth metatars W00.0XXA Fall on same level due to ice and sn 28485 RT Open Treatment Metatarsal Fracture E

AGE: 52SEX: MALEDATE OF OPERATION: 12/02/20XXPREOPERATIVE DIAGNOSIS: RIGHT ANKLE BIMALLEOLAR EQUIVALENT FRACTURE.PROCEDURES: RIGHT ANKLE ORIF LATERAL MALLEOLUS WITH SYNDESMOTIC SCREWS.POSTOPERATIVE DIAGNOSIS: RIGHT ANKLE DISPLACED (DISTAL FIBULA) LATERAL MALLEOUS FRACTURE WITH SYNDESMOSIS UNSTABILITY.SURGEON:FIRST ASSISTANT:ANESTHESIA: GENERAL VIA ENDOTRACHEAL TUBE.ESTIMATED BLOOD LOSS: 100 CC.TOURNIQUET TIME: NONE.ANTIBIOTICS: 2 GM ANCEF.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who fell from same level by slipping on ice sustaining a closed right lateral malleolar ankle fracture with displacement. Options, risks and benefits were discussed with the patient. He agreed with open reduction and internal fixation.PROCEDURE: The patient was brought to the operating room and anesthesia was induced via endotracheal tube. The right lower extremity was prepped and draped in sterile fashion.A longitudinal incisio

S93.431AN/SSprain of tibiofibular ligament of r S82.61XA Displaced fracture of lateral malleo 27829 RT Treat Lower Leg Joint 27792 RT Open Tx Distal Fibular Fracture Lat

EMERGENCY DEPARTMENTSEX: FEMALEAGE: 89DOS: 1/1/20XXArrived- By ambulance. Historian- patient and EMS personnel. HISTORY OF PRESENT ILLNESS:Chief Complaint: FOREIGN BODY SENSATION IN THROAT. This started just prior to arrival and is still present. It was abrupt in onset and has been constant. Pain described as moderate. No sore throat, mouth sores or swollen jaw or face. (Pt eating pork for lunch and had instant feeling of food stuck. Cannot swallow liquids or even saliva now.). REVIEW OF SYSTEMS:No fever, eye discomfort, cough, difficulty breathing or chest pain. No nausea, diarrhea, abdominal pain, headache or fainting episodes. No joint pain, skin rash, enlarged lymph nodes or vomiting. All systems otherwise negative, except as recorded above. PAST HISTORY: Atrial fibrillation. Diabetes mellitus. Hyperlipidemia. Hypothyroidism. Anxiety. Surgeries: Left hip prosthesis. Medications: Aspirin EC Oral.Ativan Oral.Colace

T18.128A 99284

SEX: MALEAge: 62DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS: SMALL BOWEL OBSTRUCTION.PROCEDURES: EXPLORATORY LAPAROTOMY, SMALL BOWEL ENTEROTOMY, REMOVAL OF FOREIGN OBJECT AND CLOSURE.POSTOPERATIVE DIAGNOSIS: BEZOAR OBSTRUCTING THE ILEOCECAL VALVE.SURGEON: M.D.FIRST ASSISTANT:ESTIMATE BLOOD LOSS: 20 CC.IV FLUIDS: 2 LITERS.WOUND: CONTAMINATED.DISPOSITION: POSTOPERATIVELY, THE PATIENT REMAINED INTUBATED AND WAS TRANSFERRED TO THE SURGICAL ICU.INDICATIONS: This is a male who presented in the operating room with approximately a two-day history of nausea, vomiting, abdominal distention, and inability to pass flatus or stool. Radiographic examination showed dilated bowel gas pattern. CAT scan that was done through the emergency room showed extensive dilation of most of the entire length of the small bowel with a collapsed colon. There was no area of obvious perforation nor free air in the entire CAT scan. The scan sh

T18.3XXA Foreign body in small intestine, in 44020 Enterotomy Sm Int Oth/thn Duo Expl B

Emergency Department ReportSex: FAGE: 36DOS: 01/01/20XXTime Seen: 20:42; initial patient contact.Arrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESSChief Complaint: ALLERGIC REACTION and ITCHING. This started about 4 days ago and is still present (persistent). It was gradual in onset and has been waxing/waning (Pt was seen here for an allergic reaction and possible skin infection. She is unable to determine any exact trigger for the allergy and she has never had this before. there is no one else with a rash or reaction at work or home (she lives in an apartment with 3 roommates. She was doing better after treatment 3 days ago but tonight developed some itching in the mouth and throat. She also has a tingling of her ears and scaling of the skin. she was prescribed Keflex and is now having some vaginal itching.). She has had a skin rash and itching but not had swelling or trouble swallowing. No d

T78.40XA Allergy, unspecified, initial encoun 99284 Emergency department visit for the e

OPERATION REPORTAGE: 4 mos.SEX: MALEDATE OF OPERATION: 01/01/20XXPREOPERATIVE DIAGNOSIS: LOCAL INFECTION OF BROVIAC CATHETER.PROCEDURES: REMOVAL OF TUNNELED BROVIAC CATHETER.POSTOPERATIVE DIAGNOSIS: LOCAL INFECTION OF BROVIAC CATHETER.SURGEON: M.D.Local AnesthesiaINDICATIONS: The patient is a 4 month old male with a documented local infection of the Broviac catheters. The surgery team was then notified. The surgery was requested to remove the Broviac catheter.PROCEDURE: The patient was brought into the operative suite. Once inside the operative suite, a Time Out was performed to ensure proper patient, identification as well as procedure to be performed. The patient was then placed in the supine position. The patient was then prepped and draped in the sterile fashion.Sutures to the Broviac were then cut using scalpel blade. Suture was then removed. The Broviac was still in place. Using curved Metzenbaum scissors the s

T80.212A Local infection due to central venou 36589 Rmvl Tun Cvc W/o Subq Port/pmp

OPERATIVE REPORTAGE: 58Sex: FSURGEON: Dr. Cohen Andrews, MDPREOPERATIVE DIAGNOSIS: Abdominal wound fascial dehiscence.POSTOPERATIVE DIAGNOSIS: Abdominal wound fascial dehiscence.PROCEDURE PERFORMED: Debridement of abdominal wound.ANESTHESIA: General.SKIN PREP: Betadine.DRAINS: None.INDICATIONS: This patient previously underwent laparotomy three weeks ago (by me) for peritonitis from a gastric feeding tube leak. She then developed a seroma and then an open wound. She is noted to have fascial dehiscence.FINDINGS: The fascia had become rigidly adherent to underlying tissue and could not be mobilized adequately for sufficient closure and placement of retention sutures.DESCRIPTION OF PROCEDURE: The abdomen was prepped and draped. The abdominal wound was irrigated and necrotic tissue was debrided as well as a large clotted hematoma in the depth of the wound. Fascial edges could not be easily identified or separated from th

T81.32XA 11005 78

OPERATIVE REPORTSEX: MaleAGE: 34DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Recurrent bleeding left basilica arteriovenous fistula through an old buttonhole site.POSTOPERATIVE DIAGNOSIS: Recurrent bleeding left basilica arteriovenous fistula through an old buttonhole site.PROCEDURE PERFORMED: Left AV fistula exploration and repair. Excision of buttonhole.ANESTHESIA: General.FINDINGS: His AV fistula when explored with a Fogarty balloon had calcific both proximal and distal to the area of exploration with the Fogarty catheter, but no clot within the fistula. The buttonhole site had been bleeding recurrently and actually posed a life-threatening risk with occasional nighttime bleeding. The vein was very superficial and the links of the buttonhole channel was very short which probably accounts for its recurrent bleeding characteristics.DESCRIPTION OF PROCEDURE: The patient was put under g

T82.838A Hemorrhage due to vascular prostheti 36832 Revj Opn Arven Fstl W/o Thrmbc Dial

OPERATIVE REPORTSEX: MAGE: 63DATE OF OPERATION: 1/1/20XXThis is a Commercial Payer (Follow Medicare rules for 65 and older). External causes are NOT requiredSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Thrombosed PTFE loop, AV graft, right upper arm.POSTOPERATIVE DIAGNOSIS: Thrombosed PTFE loop, AV graft, right upper arm.PROCEDURE PERFORMED: Thrombectomy PTFE loop, AV graft, right upper arm.ANESTHESIA: Local MAC.SKIN PREP: ChloraPrep.DRAINS: None.INDICATIONS: Thrombosis.DESCRIPTION OF PROCEDURE: The right arm and shoulder were prepped and draped. One percent Xylocaine was administered and previous sutures were removed and a wound opened using sharp dissection in the upper arm just below the shoulder. The graft was encircled with a vessel loop. A culture was taken of the surrounding fluid. The graft was opened through the previous graftotomy transversely and thrombus was extracted using a #4 Fogarty catheter. Exc

T82.868A Thrombosis due to vascular prostheti 36831 hrmbc Opn Arven Fstl W/o Revj Dial

Emergency Department ReportTime Seen: 16:41Arrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESSChief Complaint- LEFT HIP INJURY. The injury occurred yesterday. Occurred at a nursing home. Patient reportedly had dislocation while having her Depends changed. The patient complains of moderate pain. No blow to the head, neck pain, loss of consciousness or seizure. Not dazed.REVIEW OF SYSTEMS: The patient has had fever. No numbness, hearing loss, headache, loss of vision or chest pain. No depression, weakness, nausea, bladder dysfunction or laceration. No vomiting. All systems otherwise negative, except as recorded above.PAST HISTORY: Hypertension. hip dislocation, recent operative repair (3/10 by Gomez).SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use. Resides in a nursing home.ADDITIONAL NOTES: The nursing notes have been reviewed.PHYSICAL EXAMAppearance: Alert. Oriented X3. Patient in mild di

T84.021A T81.41XA E86.0 Y92.129 Y93.E8 99285 57 27265 LT 99152 99153

OPERATIVE NOTEPHYSICIAN:PREOPERATIVE DIAGNOSES:1. History of left breast cancer, status post-first-stage breast reconstruction with placement of tissue expander.2. Left breast cellulitis.POSTOPERATIVE DIAGNOSES:1. History of left breast cancer, status post-first-stage breast reconstruction with placement of tissue expander.2. Left breast cellulitis, with infected tissue expander.OPERATIVE PROCEDURE: Removal of left breast tissue expander with light pocket debridement and irrigation.SURGEON:ANESTHESIA: Monitored anesthesia care and IV sedation.INDICATIONS: Ms. Smith is a female who underwent immediate first-stage breast reconstruction with placement of tissue expander and AlloDerm. Shortly after surgery, she developed erythema consistent with cellulitis. She was started on oral antibiotics and after not improving, she was treated with six weeks of IV antibiotics. Her erythema had resolved and she had no pain or eviden

T85.79XA N61.0 Z85.3 Z45.812 11971 LT

ANNUAL GYN VISIT ESTABLISHED PATIENTSEX: FEMALEAGE: 22DATE: 1/1/20XXWt: 173 Ht: 64in BP: 120/82Allergies: NKDAMeds: None LMP: 12/5/12 Last Pap: Oct 2011Contraception: CondomsThis patient presents today for her physical examination and pap smear. She reports a normal menstrual pattern and flow. She has monthly menses lasting approximately 5 days. She denies any abnormal vaginal discharge, no itching, no odor. She denies any intermenstrual or post coital bleeding. Her medical history has been reviewed and is noted on her chart. She is approx. 3 months postpartum. She had a vaginal delivery with midline episiotomy. She complains today at area of repair she still notices some tenderness with intercourse. Otherwise she offers no complaints today. She does not perform self- breast examinations.ROS: Const: Denies fever and chills Resp: Denies dyspnea, no cough HEENT: Denies headache or vision changes,, no difficulty swallow

Z01.419 Encounter for gynecological examinat 99395 Periodic Preventive Med Est Patient

OFFICE - ESTABLISHEDCARDIOLOGYSEX: FEMALEAGE: 72Date of Service: 01/01/20XXPROBLEM LIST:1. Patient is a female is followed in this office for a history of moderate left anterior descending coronary disease, angiographically confirmed (20XX) and resolved with minor LAD atherosclerosis on repeat angiogram 1+ years ago.2. Positive family history for premature coronary artery disease.3. 70 pack-per-year history of smoking (none since 19XX).4. AAA stent (20XX) monitored by her physician.ALLERGIES: No known drug allergies.MEDICATIONS:Zocor 80 mg q.d.Zoloft 50 mg q.d.Saw palmetto 160 mg b.i.d.Multivitamin q.d.Aspirin 81 mg q.d.Aleve 1 tab q.d. INTERVAL HISTORY: The patient returns for preoperative evaluation prior to lumbosacral back surgery( by Dr. Smith). She has had no chest pain. No palpitations. No shortness of breath.She had a CT scan of her abdominal aorta 2 months ago showing:1. No evidence of endoleak.2. Bifurcated

Z01.810 I25.10 I72.3 Z79.82 Z95.828 99214 25 93350 93325 J1250

OFFICE - ESTABLISHEDCARDIOLOGYSEX: FEMALEAge: 80Date: 01/01/20XXCHIEF CONCERN: She is here for hospital followup.PROBLEM LIST:1. Female patient hospitalized for TIA with negative workups for CVA.2. 30-year history of hypertension.3. Moderately severe aortic valve stenosis per echo/Doppler; mild aortic stenosis per hemodynamic measurements.4. Mild nocturnal hypoxemia, suspected mild sleep apnea, using supplemental oxygen at 2 liters per nasal cannula.5. Mild COPD.6. History of hyponatremia, likely inappropriate ADS syndrome. Seeing endocrinologist.ALLERGIES: Sulfa.MEDICATIONS:Vitamin D3 5000 IU q.d.Oxybutynin 5 mg 2 q.d.Atenolol 75 mg q.a.m. and 50 mg q. p.m.Lisinopril 20 mg q.d.Simvastatin 40 mg q.d.HCTZ 25 mg q.a.m.Allopurinol 300 mg q.d.INTERVAL HISTORY:The patient is here for hospital followup. On 0X/01/20XX, she was noted by her family to have slurred speech and increased memory loss. She was admitted to the hosp

Z09 Z86.73 Personal history of transient ischem Z99.81 Dependence on supplemental oxygen 99213

SEX: MALEAGE: 47DOS: 1/1/20XXPHYSICIAN:PREOPERATIVE DIAGNOSIS: Family history of colon cancer and multiple colon polyps.POSTOPERATIVE DIAGNOSIS: Normal colon.OPERATIVE PROCEDURE: Screening Colonoscopy with Conscious Sedation. Time 19 min.SURGEON:FINDINGS: The patient is a male with regular bowel movements and no history of bleeding, and whose family, multiple people, who has had multiple colon polyps and colon cancer. His examination shows essentially normal rectum. His prostate does not feel enlarged, but is difficult to palpate because of his body habitus. The remainder of his colon is well prepared and the mucosa appears normal, without evidence of pathology. I would recommend maintaining adequate fiber intake in his diet and repeat colonoscopy at age 50, or sooner if he develops bowel habit change or bleeding.TECHNIQUE: After explaining the operative procedure, the risks, and potential complications of bleeding a

Z12.11 Encounter for screening for malignan Z80.0N/SFamily history of malignant neoplasm Z83.71N/SFamily history of colonic polyps 45378 Colonoscopy Flx Dx W/Collj Spec When 99152 Sed Same Phys/qhp Initial 15 Min

ROCEDURE: TRANSABDOMINAL PELVIC ULTRASOUNDLocation: OB/Gyn Office (Global) Sex: FemaleAge: 27DOS: 1/1/20XXCOMPARISON: None.INDICATIONS: Routine monitoring of IUD placement.TECHNIQUE: A pelvic ultrasound was completed in the usual manner.FINDINGS:UTERUS: The uterus measures 9.2 x 3.7 x 5.6 cm. An intrauterine device is seen in the endometrial cavity.OVARIES: Normal. The right ovary measures 3.2 x 1.9 x 2.6 cm, and the left ovary measures 1.7 x 2.9 x 2.0 cm.CUL-DE-SAC: Negative.BLADDER: Negative.OTHER: Negative.CONCLUSION:1. Intrauterine device in the endometrial cavity.2. Otherwise, negative transabdominal only pelvic ultrasound.Electronically signed by 1/1/20XX

Z30.431 Encounter for routine checking of in 76856 Us Pelvic Nonobstetric Real-time Ima

PATIENT INFORMATIONPatient ID: 527XXXXStudy Date: 1/1/20XXPerforming:Referring:Age: 79SEX: MaleHeight: 193 cm; BSA: 2.10 m2; Weight: 88.9 kgPerforming:ANESTHESIA: Conscious Sedation - Time: 30 minutesClinical Summary:History: PMH: Myocardial infarction.Procedure: Dual Chamber Pacemaker replacement due to end of life of batteryIndication: End of life battery status & years S/P dual chamber pacemaker implant for high grade sinus pauses.Risk factors: Dyslipidemia.Allergies: Penicillin.Labs, prior tests, procedures, and surgery:Serum creatinine (current admission) of 1.2 mg/dl. Hematocrit 46.4%. White blood cell count (WBC) 5.7 th/ul. Platelet count of 166 th/ul. Serum sodium (Na) of 140 mEq/L. Serum potassium (K) of 3.9 mEq/L. Glucose of 90 mg/dl.Blood urea nitrogen of 20 mg/dl. Hemoglobin (pre-procedure) of 15.4 g/dl.Study data: Study status: Cardiac cath: Elective. Consent: The risks, benefits, and alternatives to the

Z45.010 I25.2 33228 99152 99153

OFFICE- ESTABLISHEDCARDIOLOGYSEX: MaleAGE: 83Date: 01/01/20XXCHIEF CONCERN: He is here for AICD check and five-month check.PROBLEM LIST1. 83-year-old S/P A-V sequential biventricular AICD pacemaker (0X/01/XX) following left heart catheterization that shows 50-60% LAD stenosis; otherwise normal coronary arteriogram.2. Cardiomyopathy, ejection fraction 40-45% initially, now 50-55% following BiV optimization.3. Abnormal EKG.4. Left ventricular dyssynergy associated with left bundle-branch block.5. Hypertension; controlled.6. Type 2 diabetes with borderline control.7. Hypothyroidism, on replacement treatment.ALLERGIES: No known drug allergies.MEDICATIONSL-thyroxine 50 mcg q.d.Glipizide 5 mg b.i.d.Prednisolone eyedropsMetoprolol succ 25 mg q.d.Lisinopril 10 mg q.d.Ranitidine q.d.Metformin 500 mg q.d. (pt decreased dose from 1000 mg to 500 mg on his own and is not sure if he is taking)INTERVAL HISTORY: The patient is here

Z45.02 I10 99213 25 93289 26

RADIOLOGY REPORT Location: Mountain Hospital Sex: FemaleAGE: 60DATE OF EXAM: 1/1/20XXPHYSICIAN(S): M.D.PROCEDURE: CHEST, ONE VIEWCOMPARISON: 0X/30/20XX.INDICATIONS: Follow-up. Mechanical ventilation.TECHNIQUE: A single AP semierect portable view of the chest was performed.FINDINGS: The Endotracheal tube, endogastric tube and left upper extremity PICC remain in place. The heart size is normal. There is minimal linear opacity at the left lung base, likely residual atelectasis. No new focal lung opacities are identified. No pneumothorax is seen.CONCLUSION:1. Support lines and tubes are unchanged.2. Minimal left basilar linear opacity, likely atelectasis.Electronically signed by 1/1/20XX

Z45.2 R91.8 Z99.11 Z93.1 Z93.0 71045 26

GLOBAL POST OP OFFICE VISITSEX: FEMALEAGE: 64DOS: 1/1/20XXMD: Dr. Brandon AndrewsThe patient returns postoperatively from right total hip arthroplasty. She is ambulating with a walker today, at home with a cane. She is about three weeks out form surgery denies significant pain but is a little concerned about the incision site.PHYSICAL EXAMINATION: On examination, the incision is well healed. There is a small scab at the groin crease. There are no signs of infection. Neurovascular exam is intact. Leg lengths are symmetric.IMAGING STUDIES:X-rays taken in the office include a one-view AP pelvis and a two-view AP of right hip which shows a well-positioned and fixed Total Hip Arthroplasty (THA).PLAN:Increase activities as tolerated. Wean off walker and cane. Skin moisturizer and lotion to incision site. Return in two months for x-ray of the hip.Brandon Andrews, MDElectronically signed by BRANDON ANDREWS, MD 1/1/20XX

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WORKER'S COMPENSATIONORTHOPAEDIC FOLLOWUP REPORTSEX: MALEAGE: 38DOS: 1/1/20XXInsurance: workers compMD: Dr. Brandon AndrewsUS Department of LaborLondon, KY 40742RE: Joss SmithEMPLOYER: ABC Co.WORKER'S COMPENSATION - ORTHOPAEDIC FOLLOWUP REPORTDear Claims Examiner:Mr. Smith follows up for his right hip following arthroscopic surgery, 6 months ago. He is doing very well since his flare up that he had at his last visit. He is working out. He is riding a bike and doing elliptical. He still has not tried jogging yet. He reports some discomfort when he plants and rotates to the opposite side of his hip. He has no more pain at all when he goes up and down stairs which he had prior to surgery. He has no more popping or catching of the hip.PHYSICAL EXAMINATION:On examination, his hip has near full range of motion. He still has some discomfort with flexion combined with internal rotation and adduction.DIAGNOSIS:Status post rig

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OFFICE - ESTABLISHEDSEX: FEMALEAGE: 70DOS: 1/1/20XXMD: Dr. Brandon AndrewsThe patient returns postop dos (45 days ago)arthroscopic knee surgery. She is ambulating with one crutch. Her pain is well controlled now. She has had some nausea postop which has resolved.EXAMINATION:On exam, the knee is moderately swollen. Her range of motion is 5 to 100 degrees. Negative Homans sign.DIAGNOSIS:Status post right knee arthroscopy, lateral meniscectomy and chondroplasty.TREATMENT:The arthroscopic pictures and procedures were reviewed. A home exercise program. Handouts were provided.Return in six weeks. Brandon Andrews, MDElectronically signed by BRANDON ANDREWS, MD 1/1/20XX​

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OFFICE - ESTABLISHEDCARDIOLOGYSEX: FEMALEAGE :65Date: 01/01/20XXCHIEF CONCERN: She is here for echocardiogram results.PROBLEM LIST:1. Patient with DDD pacemaker implant (12/01/20XX), for syncopal episode, secondary to sick sinus syndrome.2. History of nonischemic cardiomyopathy, initially 30%, now estimated normal per echo (01/01/20XX).3. History of shortness of breath and chest pain, with normal coronary arteriogram (01/20XX).4. Sleep apnea, intolerant to CPAP and oral device.5. Type 2 Diabetes; well-controlled.6. S/P endoscopic gastric bypass surgery (20XX) with net 100 lb weight loss.7. History of accident resulting in concussion and neck injury (01/20XX).ALLERGIES: Penicillin, ACE inhibitors, latex adhesivesMEDICATIONS:Gabapentin 300 mg h.s.Furosemide 80 mg q.d.Ferrous sulfate 325 mg q.d.Potassium chloride ER 20 mEq t.i.d.Hydralazine 10 mg t.i.d.Paroxetine 20 mg q.d.Simvastatin 80 mg q.d.Hydrocodone 500 mg p.r.n.

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AGE: 28Sex: FProvider: Janet Jones, LCSWDate: 1/1/20XXNew Patient, Mental Health/Recovery TherapiesTime In: 10:00 Time Out: 10:53Individual Psychotherapy: 53 MinsPresenting Problem: Pregnant, 11 weeks; referred by OB. Addiction to opiates, moderate symptoms of anxiety.Reported Symptoms: HAM a score of 20, moderate anxiety, verbal report by patient minimizes symptoms. Hospital screen negative for each problems, tests indicate substance dependence. Positive for cocaine only. Reports use 3 days ago, last opiate use 2 days ago.Progress Notes: Patient is a single CF who lives with her father and stepmother locally. She was referred for Subutex maintenance due to her addiction and 11 wk. pregnancy. Patient has a Hx of drug abuse beginning after high school graduation. She has tried most drugs but reports only developing tolerance/withdrawal to opiates. She used about 50 mg Opana per day prior to pregnancy and cut down to 3

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ECHOCARDIOGRAPHY - STRESS TESTSEX: MaleAGE: 59Date: 01/01/20XXProcedure: Echocardiography, transthoracic, real-time with image documentation (2D)INDICATION: Chest pain.Medications: Ropinirole, simvastatin, omeprazole, zolpidem.Medications withheld: On all medications.Entry vital signs: BP 116/65, pulse rate 51, oxygen saturation 94% on room air.PROCEDUREResting EKG shows bradycardia at 51 b.p.m.Resting echo shows normal wall motion in all segments.The patient exercised on a standard Bruce protocol for 07 seconds into stage IVTest terminated due to fatigue and target heart rate.FINDINGSPeak heart rate of 155 b.p.m., which is 95% of maximum predicted heart rate.Blood pressure response was appropriate.Peak double product of 31,620, which represents a high cardiac workload.Peak EKG shows no ST segment changes.Oxygen saturation maintained.Exercise capacity is Functional class I at 10.2 METs.Peak exercise echo showed very

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