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: 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

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

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

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

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

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

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 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: 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

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

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

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 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

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

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

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: 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

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

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

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 - 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

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

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 - 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

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 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

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

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

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

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

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

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 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 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

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 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

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

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 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 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

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

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

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​

Z47.89 Encounter for other orthopedic after 99024 Postop Follow Up Visit Related To Or