Practicode VI (501-600)

CaseID: OPD7046 Primary Diagnosis: I83.813, I83.893, D68.51, J45.901 Secondary Diagnosis: Z79.01, Z96.642, Z86.718 E/M Level: 99202

"> MEDICAL RECORD EXAMINATION:1ST VISITSex: FemaleAge: 79DOS: 1/1/20XXHEIGHT: 5'5 1/2WEIGHT: 155 poundsHISTORY: The patient is self-referred to our clinic. She is a female and has a main complaint of her legs hurting. She has some component of unsightly veins in both legs. She has heaviness and tiredness and pain in her right leg. The heaviness and tiredness is in both legs. She has a component of itching bilaterally. She also has some discoloration of the skin. She has had open ulceration on the left in the past. She has aches and pains in her legs deemed 5/10 intensity. She has ankle swelling with dermatitis changes and night cramps. Night cramps are predominantly into the legs and toes. She has had a prior episode of cellulitis treated with antibiotics. She first noted discoloration on the left after a 19XX hip replacement. She has had bilateral hip replacements. Last checkup one month ago showed everything is great. She has a history of avascular necrosis of both hips. Her itching is present without and with compression stocking use; however, she says it is worse with the stockings. In November, she had an infected left ankle. She says that she can walk quite a way and takes care of a 5-year-old grandson. She says that she is positive for factor V Leiden disease and has had left leg surgery where she then got a blood clot. She has had no more episodes of blood clot. She is on Coumadin since 19XX when she had the episode of blood clot. This was presumably a deep vein thrombosis in the left leg. She has had prior x-rays of her hips. These symptoms markedly affect her life and prevent her from fully participating in life as she would like. She has intermittently worn compression stockings since 19XX. She states these were ordered by a physician. Occasionally they are too tight however and it is difficult to wear them.

CaseID: OPD7290 Primary Diagnosis: I50.1 Secondary Diagnosis: Z95.5, Z95.1 E/M Level: 99223

"> MEDICAL RECORD INPATIENT VISIT - INITIALSEX: MaleAGE: 83Heart Failure Admission H&P *DATE OF SERVICE: 1/1/20XXAssociated Diagnoses: Left ventricular heart failure.Basic informationSource of history: Family member.Present at bedside: Family member.Referral source:History limitation: None.Chief Complaint83 YO S/P CABG 1986, and 5 Y S/P coronary angioplasty stent.2W SOB, weak. 1 D ago sustained anterior chest pain. To VA, troponin increased, sinus tachycardia, hypoxia, bilateral pleural effusions, RX ASA, Heparin, Digoxin. TX for managementReview of SystemsConstitutional: Fatigue. Decreased activity.Eye: Negative.Ears/Nose/Mouth/Throat: Chronic postnasal discharge.Respiratory: Cough.Cardiovascular: Tachycardia. Chest pain: Midsternal.Gastrointestinal: Negative.Genitourinary: Negative.Hematology/Lymphatics: Negative.Endocrine: Negative.Immunologic: Negative.Musculoskeletal: Negative.Integumentary: Negative.Neurologic: Prior TIAs.Psychiatric: Negative.All other systems are negative.Health StatusAllergiesAllergies Reviewed.Result type: Consultation Note - PhysicianResult date: 01/01/ 20XXResult status: Auth (Verified)Result title: Heart Failure Admission H&PPerformed by:Verified by:Encounter info:Current Medications:Medications Reviewed.Histories:Procedure history:No active procedure history items have been selected or recorded.Physical ExaminationVS/MeasurementsReviewed results: Vital SignsGeneral: Alert arid oriented.Neck: No carotid bruit.Respiratory: Lungs are clear to auscultation. Decreased air entry with fine rales left base.Integumentary: 2+ bilateral SOA. Pulses intact.Review / ManagementDifferential diagnoses: Non STEMI. CHF. Possible pneumonia.Results review: Interpretation: Consistent with previous results.Chest x-ray results: Consistent with pleural effusion.Diagnostic findings: EKG N/S ST abn.Cardiac monitor

CaseID: OPD7092 Primary Diagnosis: I25.10 Secondary Diagnosis: I42.5, G47.30, E78.5, I10, Z95.1, Z79.82 CPT: 93350, 93325 E/M Level: 99214-25

"> MEDICAL RECORD 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 proximal left anterior descending and circumflex arteries, and a normal right coronary artery. She had patent LIMA to LAD and patent vein graft to the second obtuse marginal vessel.Note: She has moderate pulmonary hypotension at 46/18 secondary to elevated left ventricular filling pressures. Additionally, her right atrial pressure was elevated at 14 mmHg.She underwent a stress echocardiogram today showing:1. No evidence of ischemia.2. She is functional class II.3. No exercise-induced hypoxemia.She walks a mile slowly. She becomes short of breath with faster activity.Overnight oximetry shows:1. Oxygen saturations declining to 70%.She feels she has always been a light sleeper. She is known to snore significantly.Echo in 20XX shows:1. Early concentric left ventricular hypertrophy.2. Pulmonary artery systolic pressure elevated at 42 mmHg.Labs show:1. Lipids: LDL of 58, HDL 51, total cholesterol 148,

CaseID: OPD7467 Primary Diagnosis: Z01.419 E/M Level: 99395

">MEDICAL RECORD ANNUAL GYN VISIT ESTABLISHED PATIENT SEX: FEMALE AGE: 22 DATE: 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 swallowing CV: Denies chest pain or discomfort, No palpitations. Endo: Deferred MS: Deferred Skin: No lesions, no rashesGU: No dysuria, no genital lesions, no vaginal discharge GI: Denies N/V/D, normal appetite, no abdominal pain Resp: Denies dyspnea, no cough Breasts: No lesions/lumps, no nipple discharge or painHeme/Imm: Denies anemia or bleeding tendency.Neuro/Psych: Denies dizziness or vertigo, no anxiety/depressionGeneral: WDWN, cooperative, presents in no acute distress.HEENT: Normocephalic, no lesions, no thyromegalyLungs: CTAB, unlabored respiratory pattern observed.Heart: Rhythm is regular, rate is nml. Nml S1 & S2, no murmurs.Abdomen: Soft, flat, non tender non distended, no hepatosplenomegalyBreasts: Non tender to palp. Bilat. No lesions or dominant palpable masses, no skin or nipple changes noted on inspection, no lymphadenopathy, Implants palpated bilat.Extremities: Atraumatic, no

CaseID: OPD7411 Primary Diagnosis: S93.501A Secondary Diagnosis: S20.211A, S01.511A, W18.09XA, Y92.129 E/M Level: 99284

Emergency Department Report Patient: Smith, JaimeeAge 70 Time Seen: 1412.Attending Note: I personally interviewed the patient and examined the patient. I have personally reviewed the X-rays which were interpreted by the radiologist. HISTORY OF PRESENT ILLNESSChief Complaint- FALL. Location of injuries- right great toe and left great toe, rib, and a laceration of her upper lip. The injury occurred just prior to arrival tripped and fell to the floor over her shoes, at mom's nursing home. (Right lateral rib pains). The patient sustained a blow to the head. REVIEW OF SYSTEMSThe patient has had epistaxis (rt side, brief). laceration (inner aspect of upper lip). She has had chest pain (rt ribs, after fall). No fever, decreased vision, ear drainage or pain or toothache. No difficulty breathing, nausea, vomiting, back pain or neck pain. No alteration in mental status, dizziness, fainting episodes, headache or numbness. No weakness or enlarged lymph nodes. PAST HISTORYGERDHypothyroidism. Additional Problems:Hypothyroidism.Gastroesophageal Reflux Disease. Medications:PriLOSEC Oral 20 mg, daily as needed.Levothyroxine Sodium Oral (Tablet 50 mcg) 1 tablet, daily. Allergies: No Known Drug Allergy. ADDITIONAL NOTES13:54 01/01/20XX Weight: 70.0 kg measured. --13:54 Brian C., RN. PHYSICAL EXAMAppearance: Alert. Oriented X3. No acute distress.Vital Signs: Normal. BP: 148 / 75. HR: 97 (regular, normal rate and strong). RR: 16 (regular, unlabored and normal). Temp: 96.8 (temporal).Eyes: Pupils equal, round and reactive to light. EOM intact.ENT: No hemotympanum. No dental injury. Pharynx normal. Nose: dried nasal blood on the right side and mild tenderness. No swelling or deformity over the nose or abrasion. No septal hematoma. No malocclusion. Subcutaneous 0.5 cm laceration (inner aspect of upper lip).Neck: Painless ROM. Non-ten

CaseID: OPD6936 Primary Diagnosis: S83.512A Secondary Diagnosis: M25.362, M25.462 CPT: 29888-LT

MEDICAL RECORD AGE: 41SEX: MALEDate of Service: 1/1/20XXService Department: Orthopedic Group GeneralOPERATIVE NOTENAME OF PROCEDURE: Left knee examination under anesthesia, arthroscopy, and anterior cruciate ligament reconstruction, of an old disruption of the ACL with chronic instability.SURGEON:ANESTHESIA: General with blocks.DESCRIPTION OF PROCEDURE: With the patient in the supine position under endotracheal intubation with general anesthesia, the left knee was examined. There was a moderate amount of clear yellow effusion. There were intact collateral ligaments. There were positive Lachman, pivot shift, and drawer signs and an intact PCL.The knee was prepped and draped free in the usual manner. Portals were established inferolaterally and inferomedially.The medial component had normal cartilage in both articular surfaces, and the medial meniscus was intact to visualization and probing.The notch had large fragments of the anterior cruciate ligament caught in the notch. There was a midsubstance tear, with some tissue remaining on the femoral side and tibial side.The lateral compartment had normal cartilage in both articular surfaces. Lateral meniscus, popliteal tendon intact to visualization and probing.The patellofemoral joint had normal alignment and normal cartilage on both surfaces. Suprapatellar pouch and both gutters were clear of any loose bodies.In the notch, we paid our attention to the stump of the anterior cruciate ligament, which was removed down to bone to expose the tibial spines. We removed soft tissue from the lateral side of the notch. We performed notchplasty using a curved gouge and power instruments back to the over the top position.With the knee at 90 degrees, we used an over-the-top guide and made a proximal mid and tibial area skin incision. We placed a guidewire across the tibia to enter the j

CaseID: OPD6982 Primary Diagnosis: A63.0 Secondary Diagnosis: Z21 CPT: 46612, 99152

MEDICAL RECORD AGE: 53SEX: MALEDATE OF OPERATION:1/1/20XXPREOPERATIVE DIAGNOSIS: ANAL CONDYLOMATASPROCEDURES: FULGURATION OF ANAL CONDYLOMATAS - ANOSCOPYPOSTOPERATIVE DIAGNOSIS: ANAL CONDYLOMATASSURGEON: MDConscious Sedation: Intraservice Time 20 min.ESTIMATED BLOOD LOSS: MINIMAL.INDICATION: The patient is a 53-year-old male positive for HIV. The patient came into OR for anal condylomas.PROCEDURE: The patient was brought into the OR at 9 o'clock. The patient was put in prone position and procedure was done under local anesthesia and conscious sedation. The patient was put in prone position. The anal area was painted with Betadine and standard drapes were placed around the area. After giving 16 ccs of lidocaine IV, the anoscope was inserted in the anus and the electrocauterization was used to remove the condylomas. The whole process took about 20 minutes. All condylomatas were removed and the wound sites were cleaned. No active bleeding and Vaseline gauze was used to cover the wound site.The patient was sent to the PACU after the procedure. The patient was visited by the resident. The patient can be discharged home. Tylenol #3 and sitz bath instructions have been given to the patient and the patient can be follow up in the rectal clinic.Electronically signed by: MD 1/1/20XX

CaseID: OPD7021 Primary Diagnosis: M51.26 CPT: 63030-LT

MEDICAL RECORD AGE: 67 Sex: F DATE OF OPERATION: 1/1/20XX PREOPERATIVE DIAGNOSIS: HERNIA DISC L4-5. PROCEDURES: L4-5 LAMINECTOMY, MEDIAL FACETECTOMY AND DISCECTOMY. POSTOPERATIVE DIAGNOSIS: HERNIA DISC L4-5 LT SIDE SURGEON: ANESTHESIA: GENERAL, ENDOTRACHEAL. INDICATIONS: This is a woman with severe leg pain, difficulty walking, weakness of the left leg reflexion of the foot, straight leg raising exam was positive. Imaging study showed a very large, extruded disc herniation L4-5 compression of the thecal sac. The patient was scheduled for surgery. After discussing the risks, benefits and possible complications of procedure, wished to proceed. PROCEDURE: The patient was brought to the operating room and placed in the supine position. After appropriate monitoring lines and Foley catheter was placed, she was given general anesthesia and turned to the prone position on the Wilson frame. The back was prepped and draped in usual fashion. Localizing fluoroscopic image was taken. Once this was done, a midline skin incision was made. Dissection continued through soft tissues Bovie electrocautery. The fascia was opened in the midline and the paraspinal muscles were elevated of both sides of lamina eccentric to the left side which was symptomatic. Cerebellar retractors were placed. Using Leksell rongeurs, the laminectomy of bottom of L4, top of L5 was performed. The drill was used to thin out the medial facet on the left side. Medial fasciectomy was performed on the left this allowed mobilization of the dura in the nerve roots, which was identified. There was a large disc herniation extending above the disc space and complete compressing the ventral epidural space, this was carefully dissected away with a #4 Penfield dissector away from the dural and portions which were stuck were carefully dissected using Down-pointing curettes.

CaseID: OPD7382 Primary Diagnosis: N95.0 Secondary Diagnosis: R87.618 CPT: 57505

MEDICAL RECORD AGE: 75SEX: FEMALEPREOPERATIVE DIAGNOSIS: POSTMENOPAUSAL BLEEDING. ABNORMAL PAP TEST- ENDOMETRIAL CELLS PRESENTPROCEDURES: ATTEMPTED ENDOMETRIAL CURETTAGE.POSTOPERATIVE DIAGNOSIS: POSTMENOPAUSAL BLEEDING. SURGEON: Joshua Kramer, M.D.FIRST ASSISTANT: ANESTHESIA: GENERAL, ENDOTRACHEAL TUBE ESTIMATE BLOOD LOSS: LESS THAN 5 CC.FLUID INPUT: 300 CC OF LRURINE OUTPUT: 100 CC OF CLEAR URINE.SPECIMEN: ENDOCERVICAL CURETTAGE.COMPLICATIONS: NONE.DISPOSITION: THE PATIENT WAS TAKEN TO THE RECOVERY ROOM IN STABLE CONDITION.FINDINGS: Atrophic vagina, large cystocele, cervix cannot be visualized and palpated readily.PROCEDURE: After obtaining informed consent, the patient was taken to the operating room and general anesthesia and endotracheal tube was initiated, the patient was placed in the dorsal lithotomy position. The peritoneum was prepped and draped in sterile fashion. The bladder was drained by straight catheter. A retractor was placed into the posterior vagina. A right angle retractor was positioned anterior to the cervix. Then the anterior lip of the cervix-cont. with the anterior vaginal wall and very difficult to isolate was grasped with a single-tooth tenaculum. With difficulties endocervical canal localized and endocervical curettage was performed using the Kevorkian curette. Minimal amount of tissue obtained and sent for pathology. Hysteroscopy was not performed due to inability to penetrate internal cervical os. The instruments were removed from the cervix and the vagina. Excellent hemostasis was obtained.The patient tolerated the procedure well. Sponge counts were correct x 2. Patient was transferred to recovery room in stable condition.__________________________Joshua Kramer, M.D.DICTATED BY: J Andrews, M.D.

CaseID: OPD6939 Primary Diagnosis: M77.12 CPT: 24359-LT

MEDICAL RECORD 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 tendon was sutured together. The anterior aspect of the lateral epicondyle was roughened with a rongeur. The wound was then irrigated, and the subcutaneous tissue was closed with 2-0 Vicryl and skin with wire staples. A sterile dressing was applied.The patient was taken to the recovery room in satisfactory condition with a splint in place.Electronically signed by 1/1/20XX

CaseID: OPD7011 Primary Diagnosis: K43.5 CPT: 49621

MEDICAL RECORD Age: 68SEX: FEMALEDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: PARACOLOSTOMY HERNIA.PROCEDURES: EXPLORATORY LAPAROTOMY, LYSIS OF ADHESIONS AND REPAIR PARACOLOSTOMY HERNIA WITH MESH.POSTOPERATIVE DIAGNOSIS: PARACOLOSTOMY HERNIA.SURGEON:ANESTHESIA: GENERAL, ENDOTRACHEAL.ANESTHESIOLOGIST:ESTIMATE BLOOD LOSS: APPROXIMATELY 50 ML.IV FLUIDS: 1200 ML CRYSTALLOID.URINE OUTPUT: 250 ML.COMPLICATIONS: NONE.FINDINGS: Paracolostomy hernia containing multiple small bowel loops. Multiple adhesions of the small bowel.PROCEDURE: The patient was taken to the operating room and laid down supine on the OR table. General anesthesia was initiated by way of endotracheal intubation. The area over the abdomen was scrubbed, prepped and draped in the usual sterile surgical fashion.The previous scar mark was then used to make an incision over midline abdomen. The incision was carried down through the subcutaneous tissue using electrocautery while establishing simultaneous hemostasis. Then a rigid portion of the belly was opened up in the midline fascia and this was used to extend down towards until we could visualize all the adhesions to the small bowel which were taken down sharply with Metzenbaum scissors.Once extensive lysis of adhesions was done we could see the hernia containing small bowel loops in the paracolostomy hernia site which was reduced. The defect was visualized and the posterior rectus sheath was then detached on the medial edge and flaps were then developed both from each medial edge laterally. Once adequate flaps were developed, a Prolene mesh was then used and placed superficial to the posterior rectus sheath and deep to the rectus muscle. An aperture was fashioned in the mesh using a keyhole incision.The posterior rectus sheath was then closed using a continuous 2-0 Vicryl suture. The anterior rectus shea

CaseID: OPD6986 Primary Diagnosis: K62.3 CPT: 45900

MEDICAL RECORD 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 buttocks were taped together to discourage re-prolapse.The patient was then returned back into the supine position. The patient was awoken in the operating room and taken to the recovery room. Sponge, needle, and instrument counts were correct at the end of the case.Electronically signed by: MD 1/1/20XX

CaseID: OPD6950 Primary Diagnosis: M16.11 CPT: 20610-RT, 77002

MEDICAL RECORD Age: 87 Sex: FEMALEDate of Service: 01/01/20XXService Department: Orthopedic Group General Clinic DIAGNOSIS: Right hip joint primary osteoarthritis.PROCEDURE: Right hip cortisone injection.SURGEON: Dr. MDDESCRIPTION OF PROCEDURE: The patient was placed on fluoroscopy table in a supine position. The right hip was identified under fluoroscopy. The skin was prepped with Betadine, skin anesthetized with 1% lidocaine. Under fluoroscopy guidance, a 22-gauge needle was guided into the right hip capsule using anterolateral approach. Confirmation made by injection of a small amount of contrast. Once this was confirmed, injection of bupivacaine and Kenalog was placed in the hip capsule. The patient tolerated the procedure well without complications, leaving the department in improved, stable condition. We will see her back to follow up in the office for recheck and reevaluation. Reinjections as needed.Electronically signed by: MD 1/1/20XX

CaseID: OPD7103 Primary Diagnosis: I49.3, J61, I27.23, I34.0, I34.1, R55 Secondary Diagnosis: Z77.090 E/M Level: 99204-25

MEDICAL RECORD CARDIOLOGY - NEW PATIENTAGE: 82Sex: MConsulting Physician:Referring Physician:Date: 01/01/20XXHISTORY OF PRESENT ILLNESS: Patient is a male, new pt, referred by his physician with a history of pulmonary asbestosis and pulmonary hypertension. He has had some evaluation of exertional shortness of breath per his physician, leading to a CT scan of the chest on 12/01/20XX. This showed enumerable calcified pleural plaques compatible with prior asbestos exposure as a carpenter, slight basilar scarring.CORONARY RISK FACTORS1. Hypertension for four years.2. He is not obese, BMI 29.3. Nonsmoker.4. Nondiabetic.5. No recent lipid panel.PAST MEDICAL AND SURGICAL HISTORYMedical: No cancer. No hepatitis. No periodontal disease. Hospitalized three years ago for hypertension.Surgical: Lumbar surgery at age 46, reconstruction of jaw, and hernia surgeries x2. He also underwent dilation for an esophageal stricture.ALLERGIES: Xopenex inhaler (syncope).MEDICATIONSAtenolol 25 mg b.i.d.Hydrocodone 5/350 mg t.i.d.SOCIAL HISTORY: He is widowed and has no children. He has lived in Florida for 30 years and is a retired carpenter.FAMILY HISTORY: Noncontributory.REVIEW OF SYSTEMSCARDIOVASCULAR: Carotid Doppler study two years ago showed < 50% bilateral carotid artery stenosis. He underwent an echocardiogramon 12/15/20XX, a CT of the chest on 12/15/20XX, and a chest x-ray on 12/15/20XX. He has occasional palpitations at nighttime. No historyof claudication-type symptoms, murmur, or rheumatic fever.RESPIRATORY: He has refused to undergo an overnight sleep study for daytime sleepiness through his physician. He had work-related asbestos exposure 50 years ago. No asthma, emphysema, hemoptysis, cough, or shortness of breath.GASTROINTESTINAL: No hiatal hernia, dyspepsia, ulcers, or hemorrhoids. Unrestricted diet. Alcohol intake: None. Caffe

CaseID: OPD7506 Primary Diagnosis: I48.20 CPT: 93306-26

MEDICAL RECORD CARDIOLOGYSEX: MALE AGE: 66 Transthoracic Echocardiography ReportComplete 2D Study with M-Mode, Complete Spectral Doppler, and Color Doppler 01/01/20XXINPATIENT Ht 70 in (177.8 cm) Wt 199.5 lb (90.7 kg) BSA 2.09 m squaredDiagnoses:- CHRONIC ATRIAL FIBRILLATIONEcho 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. COMPARISONS: Comparison was made with the previous study of 012/05/20XX. Overall RV function has improved. Otherwise no interval change.HISTORY: PRIOR HISTORY: Risk factors: hypertension, insulin-controlled diabetes, recent cocaine abuse, and a history of current cigarette use (within the last month). Cerebrovascular disease. PROCEDURE: The procedure was performed at the bedside. This was a routine study. The transthoracic approach was used. Complete 2D echocardiography study was performed with M-mode, complete spectral Doppler, and color Doppler. The heart rate was 76 b.p.m. at start. Systolic blood pressure was 161 mmHg at start. Diastolic blood pressure was 82 mmHg at start. Images were obtained from the parasternal, apical, and subcostal acoustic windows. Image quality was adequate. LEFT VENTRICLE: Size was normal. Systolic function was normal. Ejection fraction was estimated in the range of 55% to 65%. There were no regional wall motion abnormalities. Wall thickness was normal. DOPPLER: The ratio of early ventricular filling to atrial contraction velocities was within normal range.AORTIC VALVE: The valve was trileaflet. Leaflets exhibited normal thickness and normal cuspal separation. DOPPLER: Transaortic velocity was within normal range. There was no evidence for stenosis. There was no aortic regurgitation. AORTA: The root exhibi

CaseID: OPD7093 Primary Diagnosis: I10, J44.9, I44.2 Secondary Diagnosis: Z95.0 E/M Level: 99212

MEDICAL RECORD CARDIOLOGYSex: FemaleAGE: 90Date: 01/01/20XXOffice Visit for results:PROBLEM LIST1. A female, 14 yrs ago S/P dual-chamber pacemaker for complete heart block, generator replaced for battery at end of life status three years ago.2. Hypertension.3. Multivessel CABG (20XX).4. Chronic lumbosacral pain.5. Hyperkalemia associated with renal tubular dysfunction.6. Hypothyroidism, on replacement therapy.7. Mild COPDALLERGIESSulfa, HCTZ (leg pain), procainamide (cough), ACE inhibitor (cough), metoprolol (kg and thigh pain), Amlodipine 10mg — hives (tolerates 5mg)MEDICATIONSVerapamil 360 mg q.d.Fosamax 70 mg every other weekZocor 10 mg q.d. (Simvastatin)Synthroid 50 mcg q.d.Losartan 100 mg q.d.Calcium plus D b.i.d.Multivitamin q.d.Biotin 300 mcg q.d.Vitamin D 1000 IU q.d.Omega fish oil 1000 mg q.d.Lutein 20 mg q.d.Ambien 10mg q h.s.Oxycodone p.r.n.CoQ1O q.d.INTERVAL HISTORY: The patient is doing beautifully. She ambulates without difficulty. She continues to volunteer at the hospital. Systolic blood pressure has been running slightly high, in the 140s to 150s, but stable as per her blood pressure diary. Physical activity is limited somewhat by left knee arthritis. She climbs steps with caution. She has had no falls.PHYSICAL EXAMVITAL SIGNS: Weight 129 lbs., HP 134/72 in the left arm, pulse 74 and regular and oxygen saturation 93% on room air.CONSTITUTIONAL: Alert and oriented x3. Skin: Pink, warm and dry.RESPIRATORY: She purse-lip breathes frequently during conversation and with activity. Lungs are diminished. No adventitious sounds. Chest has normal contour.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest

CaseID: OPD7265 Primary Diagnosis: R22.0 Secondary Diagnosis: Z96.22 E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENT SEX: FEMALE AGE: 1 DOS: 1/1/20XX Time Seen: 17:06 1/1/20XX. Historian- mother and grandmother. HISTORY OF PRESENT ILLNESS Chief 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 immune 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). Medications: None. Allergies: No Known Drug Allergy. SOCIAL HISTORY: Resides in a house. The patient lives with parent (s). ADDITIONAL NOTES: The nursing notes have been reviewed with agreement regarding the chief complaint, HPI, ROS, PMH and patient medications and allergies. 16:32 01/01/20XX Weight: 10.6 kg measured. --16:32 Rachel L., R.N. PHYSICAL EXAM: Appearance: Alert. Oriented X3. No acute distress. O2 sat monitor on the patient. (swollen L parotid area, apparently NT). Vital Signs: Have been reviewed and normal and appear to be correct. (HR: 117. RR: 24. Temp: 98 (temporal). O2 saturation: 97 % room air.). Eyes: Pupils equal, round and reactive to light. Conjunctivae and eyelids normal. ENT: Ears normal. Nose normal. Pharynx normal. (TT's in place, no d/c from nl TMs). Neck: Neck supple. No lymphadenopathy. CVS: Normal heart rate and rhythm. Heart sounds normal. Respiratory: No

CaseID: OPD7418 Primary Diagnosis: I25.10, E78.5, I47.20, Z95.1 CPT: 93010, 93010-76 E/M Level: 99285-25

MEDICAL RECORD EMERGENCY DEPARTMENT SEX: MALE AGE: 83 DOS: 1/1/20XX Time Seen: 2345. Arrived- By private vehicle. Historian- patient and family. HISTORY OF PRESENT ILLNESS:Chief Complaint: CHEST PAIN. This started today all day. 3 bad spells and is still present. It was abrupt in onset and has been intermittent. It is described as pressure and tightness and it is described as located in the central chest area and radiating to the jaw. At its maximum, severity described as moderate. When seen in the E.D., severity described as moderate. Modifying factors- Not worsened by anything. Not relieved by anything. No nausea, vomiting, difficulty breathing or diaphoresis. Similar symptoms previously: None. Recent medical care: The patient was seen recently in the office. (Dr Jones. admitted 4 months ago. angiogram. no stent). REVIEW OF SYSTEMS: No fever, chills, cough, pedal edema or calf pain. No fainting episodes, headache or abdominal pain. All systems otherwise negative, except as recorded above. PAST HISTORY: Coronary artery disease. Hyperlipidemia. Risk factors for heart disease- hypertension and elevated cholesterol; for thoracic aortic dissection- hypertension; for DVT/pulmonary embolism- advanced age. Denies the following risk factors for heart disease - smoking and diabetes. Denies the following risk factors for thoracic aortic dissection - connective tissue disorder and prior history of thoracic aortic dissection. Denies the following risk factors for DVT/PE - history of DVT, cancer and clotting disorder. Surgeries: Appendectomy. Cardiac procedures- Has had coronary bypass operation with subsequent redo bypass. Medications: Carvedilol Oral. Simvastatin. Carvedilol and Diet Manage Prod Oral. Simethicone Oral. Allergies: NKDA. SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use. ADDITIONAL NOTES: The nursing notes hav

CaseID: OPD7257 Primary Diagnosis: S16.1XXA Secondary Diagnosis: M54.50, G89.29, V53.5XXA E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENT SEX: Male AGE: 34 DOS: 1/1/20XX Time Seen: 14:41; initial patient contact. Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS Chief Complaint- MOTOR VEHICLE COLLISION. Location of injuries- neck, lower back and left knee. The injury occurred yesterday. The patient complains of severe pain. The patient complains of neck pain. No blow to the head, loss of consciousness or seizure. Not dazed. Mechanism details- Patient driving and was wearing a lap belt and shoulder harness. The accident involved two vehicles and a moderate impact velocity and resulted in mild damage to the patient's vehicle. Patient was ambulatory at the scene. The air bag did not deploy. The vehicle did not overturn. The patient was not ejected from the vehicle. The windshield was not starred. The steering wheel was not broken. There was not a prolonged extrication. No fatality involved. Additional history - (Pt was driving his pick up with a trailer. a SUV failed to stop and drove up onto his trailer and jostled the pick up. the pt has chronic neck and back pain from prior MVA 7 years ago. He is followed by a single doctor and is compliant with his medications. he reports the pain is much worse after the accident. he ran out of his medications yesterday He has no weakness or numbness and no bowel or bladder problems.).REVIEW OF SYSTEMS: No numbness, dizziness, loss of vision, hearing loss or chest pain. No difficulty breathing, weakness, headache, nausea or abdominal pain. No fever or depression. All systems otherwise negative, except as recorded above.PAST HISTORY: chronic neck and back pain. Risk factors for neck injury- prior neck injury. Denies the following risk factors for neck injury - greater than 40 years of age and history of ankylosing spondylitis and severe osteoarthritis. Medicat

CaseID: OPD7252 Primary Diagnosis: N40.1 Secondary Diagnosis: R33.8, I10, Z79.899, Z87.442 E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENT SEX: Male AGE: 69 DOS: 1/1/20XX Time Seen: 06:03 Arrived- By private vehicle. Historian- patient. HISTORY OF PRESENT ILLNESS Chief Complaint: URINARY RETENTION. This started last night and is still present. It was gradual in onset and has been constant. The problem is described as moderate. He has had discomfort with urination and urgency of urination and been unable to void and voiding small amounts. The patient has had urinary frequency. No penile discharge. Sexual history is noncontributory. Similar symptoms previously: None. REVIEW OF SYSTEMS: No fever, chills, flank pain, hematuria or abdominal pain. No vomiting, diarrhea, headache, sore throat or chest pain. No difficulty breathing, cough, joint pain or skin rash. All systems otherwise negative, except as recorded above. PAST HISTORY: Myocardial infarction. Hypertension. Benign prostatic hypertrophy. Urinary calculi. Risk factors for abdominal aortic aneurysm- hypertension. Denies the following risk factors for abdominal aortic aneurysm - connective tissue disorder, smoking, family history of abdominal aortic aneurysm and prior abdominal aortic aneurysm. Surgeries: Appendectomy. Right and left hip prosthesis. Tonsillectomy. Medications: Lisinopril Oral. Lortab Oral. Metoprolol. Tramadol HCL Oral. Allergies: Percodan. SOCIAL HISTORY: Nonsmoker. No alcohol use. ADDITIONAL NOTES The nursing notes have been reviewed. Weight: 94.3 kg measured. Height: 69 inches Per Patient. BMI: 30.7.PHYSICAL EXAM: Appearance: Alert. Oriented X3. Appears to be in pain. Patient in moderate distress.Vital Signs: (BP: 164 / 82 R arm auto sitting. HR: 74 regular. RR: 20 regular. Temp: oral97 F. O2 saturation: room air -97 percent.). ENT: Normal external inspection. Pharynx normal. Neck: Neck supple. CVS: Heart sounds normal. Respiratory: No respiratory

CaseID: OPD7066 Primary Diagnosis: D64.9 Secondary Diagnosis: R09.02, I50.9, K92.2, D68.32, T45.515A, Z96.651, Z79.01 CPT: 93010 E/M Level: 99285-25

MEDICAL RECORD EMERGENCY DEPARTMENTAGE: 78Sex: FDOS: 01/01/20XXCHIEF COMPLAINT: Shortness of breath.HISTORY OF PRESENT ILLNESS: The patient is a female status post right total knee replacement one week ago performed at an outpatient hospital in Fremont, California, who is presenting with shortness of breath that has been getting worse for the last two days. The patient says that she had an uncomplicated surgery and was discharged. She was doing well postoperatively and was doing well with physical therapy until about two days ago when she started to feel shortness of breath and for the last two days it has been getting progressively worse. She is now mildly short of breath even at rest. The patient is concerned about her hemoglobin. She says that it was 8.6 when she was discharged. She has been taking iron for that. She is also on Coumadin for prophylaxis for DVT. She denies any fevers or chills. No chest pain, no cough, no sputum production. She is noticing bilateral lower extremity swelling and it seemed worse in her left foot today. She is ambulating with her walker without difficulty. She denies any melena or bright red blood per rectum. No dysuria, urgency or frequency. No focal weakness or numbness.The patient says that it is possible that she has had shortness of breath with severe exertion on and off for the last several months but really had not noticed it until approximately two days ago.PAST MEDICAL HISTORY: (1) Chronic back pain on a pain pump. (2) Hypertension. (3) Dyslipidemia.PAST SURGICAL HISTORY: Right total knee replacement one week ago.CURRENT MEDICATIONS:CoumadinIronMultivitaminTylenol #4AtenololCelecoxibEnalaprilFenofibrateFentanyl infusion pumpHydrochlorothiazideMorphine infusion pumpZegeridALLERGIES: No known drug allergies.REVIEW OF SYSTEMS: Complete review of systems was obtained and is negativ

CaseID: OPD7228 Primary Diagnosis: J44.1 Secondary Diagnosis: E87.1, R93.89, M85.80, Z87.440, Z87.09 CPT: 93010, 93042-59 E/M Level: 99285-25

MEDICAL RECORD EMERGENCY DEPARTMENTAGE: 89 Sex: FDOS: 01/01/20XXTime Seen: 15:09 Arrived- By private vehicle. Historian- patient and family. Note: Previous visits to this facility for similar complaints.HISTORY OF PRESENT ILLNESS:Chief complaint- DYSPNEA and HISTORY OF ASTHMA and WHEEZING. This started several days ago and is still present and now worse. It is not improving. It was gradual in onset and has been constant. The dyspnea is described as moderate. The dyspnea is worsened by walking, exertion, being in a supine position and cough, is improved by rest, is improved with oxygen and is improved with sitting upright. She has had a subjective low grade fever. The patient has had a moderate cough, wheezing, dyspnea on exertion and dizziness. No chest pain or discomfort, calf pain or foot swelling.Similar symptoms previously: She has had similar symptoms several times previously.Recent medical care: The patient was seen recently at this facility and hospitalized (12 days ago). (s/p normal ventilation-perfusion (VP) scan). Seen for similar symptoms.REVIEW OF SYSTEMS: The patient has had nausea but not had weight loss. She has had difficulty with urination (chronically). No muscle aches, eye irritation, sore throat, nasal discharge or sinus drainage. No vomiting, abdominal pain, diarrhea, black stools or headache. No fainting episodes, blurred vision, excessive urination, skin rash or enlarged lymph nodes. No joint pain. All systems otherwise negative, except as recorded above.PAST HISTORY: Multiple episodes of UTI.Denies the following risk factors for heart disease - smoking, diabetes and elevated cholesterol. Denies the following risk factors for thoracic aortic dissection - connective tissue disorder, prior history of thoracic aortic dissection and coarctation of the aorta. Denies the following risk factors for abdo

CaseID: OPD7232 Primary Diagnosis: R55, I95.9, I48.20, I25.10 Secondary Diagnosis: Z79.01, I25.2 CPT: 93010 E/M Level: 99285-25

MEDICAL RECORD EMERGENCY DEPARTMENTAge: 90 SEX: FEMALEDOS: 01/01/20XXArrived - By ambulance. Historian - patient and EMS personnel. Note: Previous visits to this facility for Other complaints.HISTORY OF PRESENT ILLNESS:Chief Complaint - SINGLE SYNCOPAL EPISODE: It was abrupt in onset and has been constant (episode lasting 2 minutes). This occurred just prior to arrival. She has recovered. Event was witnessed. Witnessed by daughter. She had no preceding symptoms. At time of event, she was sitting. She lost consciousness, was apneic and collapsed. The patient was incontinent of urine. No seizure activity. Did not lose pulse. Had a single episode. The episode lasted minutes. No injuries noted. Currently she feels normal. Currently has mild headache. No weakness currently. No nausea currently. Similar symptoms previously: NoneRecent medical care: (PMD) Not recently seen / assessed.REVIEW OF SYSTEMS: The patient has had weakness and palpitations. No headache, chest pain, abdominal pain, vomiting or diarrhea. No black stools. Has foot infection on Keflex per Podiatry. All systems otherwise negative, except as recorded above.PAST HISTORY: Atrial fibrillation. Coronary artery disease. Myocardial infarction 2yrs ago, Hypertension, UTI, Chronic back pain. Right humerus fracture. S/p internal fixation.SURGERIES: Back Surgery, Bowel Surgery, Had Hysterectomy. Rotator cuff surgery.MEDICATIONS:Aspirin EC Oral.Cephalexin Oral.Coumadin Oral.Cranberry Concentrate Oral.Glucosamine HCl Oral.Hydrocodone-Acetaminophen Oral.Lasix Oral.Lyrica Oral.Stool Softener Oral. --Aspirin.ALLERGIES: No known Drug AllergySOCIAL HISTORY: Nonsmoker. No alcohol use or drug use. PHYSICAL EXAM:Appearance: Alert. IV present X 1. EKG 12 lead interpretation and review by me:Findings: Abnormal rhythm with occasional extra systoles. Pulses normal. No cardiac murm

CaseID: OPD7068 Primary Diagnosis: K92.2 Secondary Diagnosis: Z79.01 E/M Level: 99291

MEDICAL RECORD EMERGENCY DEPARTMENTCRITICAL CARESex: MAGE: 74DOS: 01/01/20XXCHIEF COMPLAINT: Black stools.HISTORY OF PRESENT ILLNESS: This is a male who states that last night he had a really hard stool. He had used some Vaseline to get it out, and it hurt. But he was able to get it out, felt a little better afterwards. This morning, however, he just had this horrible, black, diarrhea stool, could hardly control it. He has been very lightheaded today; states he just feels horrible. He has been having people tell him for the last 48 hours that he looks lousy, pale. He has been feeling poorly. Denies abdominal pain, denies fevers, chills, URI symptoms. No chest pain. He is not nauseated. Denies any back pain. No rashes or easy bruising.PAST MEDICAL HISTORY: Significant for chronic coronary artery disease, congestive heart failure, a-fib. He is on anticoagulants. He has elevated cholesterol. He has a valvular disorder. He has some chronic low back pain, gout, sciatica, spinal stenosis, Hep C.SOCIAL HISTORY: The patient smokes. He occasionally uses alcohol, marijuana, opiates, and prescription pain relievers.FAMILY HISTORY: Noncontributory.REVIEW OF SYSTEMS: Only positive as above, all other areas negative.MEDICATIONS:Tamsulosin.Sotalol.Spironolactone.Warfarin.D-S-S.Methadone.ALLERGIES: None.PHYSICAL EXAM: VITAL SIGNS: Temperature 96.9; pulse 120; respiratory rate is 20; pulse ox is 100% on 2 liters; blood pressure 79/59. GENERAL: The patient is alert and oriented with clear speech and mentation. Pleasant elderly male, resting, lying flat, comfortable on the gurney. HEENT: Pupils are equal, round, and react to light. Extraocular movements are intact. Nose without evidence of discharge. Mucous membranes are pale. Oral is clear with slightly dry mucous membranes, no intraoral lesions. Mucous membranes are pale, as stated. Fa

CaseID: OPD7441 Primary Diagnosis: S62.300K Secondary Diagnosis: S62.302D CPT: 73120-RT E/M Level: 99212-25

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

CaseID: OPD7216 Primary Diagnosis: L22 E/M Level: 99283

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: FEMALE AGE: 4 monthsDOS: 1/1/20XXCC: Diaper RashHISTORY OF PRESENT ILLNESS: The patient is a 4-month-old female who presents to the emergency department with a 1 day history of increased diaper rash. Her mother states that it was bleeding at times during the day today because it had become so severe. She states that she tried putting Desitin on it this morning, however it does not seem to be helping. She states that the patient has had some loose stools recently and has had an increased stooling pattern. She has not had any fevers. The patient does have a skin condition for which she is being treated by Bactroban as well as hydrocortisone. She was started on these in December by Dr. Thomas. She last saw Dr. Thomas of 01/02/20XX and was told to continue these creams. These creams, however, are not used in the diaper area; they are used apparently on the face for the Bactroban and the rest of the body for the hydrocortisone.PAST MEDICAL HISTORY: The patient was a full-term infant. She was born via C-section. She went home from the hospital with Mom, no extended stay. She does have a history of a skin infection. This very well may be eczema.IMMUNIZATIONS: Up to date.SOCIAL HISTORY: The mother denies any exposure to second-hand smoke.HOME MEDICATIONS:Bactroban.Topical hydrocortisone.ALLERGIES: NO KNOWN DRUG ALLERGIES.REVIEW OF SYSTEMS: As per HPI; all other systems are negative.PHYSICAL EXAM: VITAL SIGNS: Heart rate 155, respiratory rate 52, temperature 98.7 degrees. She is 100% on room air. GENERAL: The patient is alert. She is in no apparent distress. She is nontoxic appearing. She does have some increased fussiness with examination, however she is always easily consolable by her mother. HEENT: Oropharynx is clear. Mucous membranes are moist. Anterior fontanel is open, soft, and fl

CaseID: OPD7219 Primary Diagnosis: R20.2 Secondary Diagnosis: F41.9, F17.210 E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: FEMALE AGE: 62DOS: 1/1/20XXCHIEF COMPLAINT: Left arm numbness.HISTORY OF PRESENT ILLNESS: This is a female who complains of chronic arthritis type pain. Has had a lot of pain in the wrist and hands for the last 2 days and then left arm that developed as well as left shoulder pain and left side of the face numbness. The patient states that she had no motor weakness, no change in vision, hearing, speech, or balance. No change in muscular strength in arms or legs. She denies headaches. Denies neck stiffness. Denies any other symptoms. She has had no chest pain or shortness of breath, no strain or overuse. No rash on the skin.ALLERGIES: PENICILLIN, CODEINE, LEXAPRO.REGULAR MEDICATIONS:Supplements.Carisoprodol.Celecoxib.Oxycodone p.r.n.Estrogens.Amlodipine.Darifenacin.Pantoprazole.PAST MEDICAL HISTORY: Positive for hepatitis C, chronic arthritis.SOCIAL HISTORY: Denies alcohol, half pack per day smoker.REVIEW OF SYSTEMS: Negative except for above.FAMILY HISTORY: Noncontributory.PHYSICAL EXAMINATION: VITAL SIGNS: Stable. Temperature is afebrile at 97.6, tympanic. Pulse oximetry excellent on room air 97%. Blood pressure 194/83. SKIN: Warm, pink, dry, no rash. HEENT: Exam essentially all negative. EYES: PERRLA. EOMI. Normal mucous membranes, good hydration is noted. NECK: Supple without lymphadenopathy. CHEST: Clear to auscultation. CARDIAC: Regular rhythm without murmur, rub or gallop. ABDOMEN: Benign. Bowel sounds present. Soft to palpation in all quadrants without organomegaly, masses noted. CHEST: Chest wall nontender to palpation. EXTREMITIES: Left arm; full range of motion without pain and neuro and vascularly intact in upper and lower extremities. No motor weakness noted. No facial asymmetry noted. No cranial nerve abnormalities noted. SKIN: Shows no rash dermatomal or otherwise. N

CaseID: OPD7326 Primary Diagnosis: S67.195A, S61.315A Secondary Diagnosis: W23.0XXA, Y92.213 CPT: 11730-F3, 73120-52-LT E/M Level: 99213-25

MEDICAL RECORD MEDICAL RECORD OFFICE VISIT DATE OF SERVICE: 1/1/20XXSUBJECTIVE: The patient, who is an established patient, injured his left ring finger this afternoon at high school when a door was slammed on it by another careless student. He has suffered a traumatic partial avulsion of his nail with lacerations to the distal phalanx but no apparent injury to the DIP joint. He was initially evaluated in the office at the home for definitive evaluation and treatment. He is accompanied by his host at the home, Sam, for the initial part of the evaluation and then for the remainder of the exam and treatment is accompanied by Julie, RN.PHYSICAL EXAMINATION: The patient is ambulatory on arrival and when the gauze dressing was removed there was some moderate bleeding and oozing. He has surprisingly minimal pain. Distal neurovascular function intact. A digital block was performed by injecting 1 mL of 2% lidocaine without epinephrine into the flexor sheath on the palm of the hand at the base of the ring finger and this provided adequate anesthesia. The finger was prepped with Betadine solution and draped in a sterile fashion and the partially avulsed nail was easily removed with just a few snips using a sterile scissor and a hemostat. The nail bed itself appears to be intact although there is hematoma formation in 2 places. There are superficial laceration lines on the finger pad side of the finger, but no laceration is deep to the dermis.DIAGNOSTIC DATA: X-ray single AP view of left hand taken in the office shows no burst or other type of fracture, specifically the proximal growth plate of the distal phalanx is normal as is the DIP joint. IMPRESSION: Crush injury, left ring finger, distal phalanx without fracture, partial avulsion of nail plate. Tetanus status is up to date with an Adacel booster given in June 20XX.PLAN:1. T

CaseID: OPD7226 Primary Diagnosis: S29.012A Secondary Diagnosis: Y92.017, Y93.H2 E/M Level: 99283

MEDICAL RECORD 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 had similar symptoms previously.REVIEW OF SYSTEMSNo fever, chills, eye discomfort, headache or depression. No sore throat, cough, difficulty breathing, chest pain or skin rash. No abdominal pain, nausea, vomiting, diarrhea or difficulty with urination. No urinary frequency or hematuria. All systems otherwise negative, except as recorded above.PAST HISTORYHypothyroidism. History of migraine headaches. Ovarian cyst. Anxiety. Depression. Fibromyalgia.Denies the following risk factors for neck injury - greater than 40 years of age and history of ankylosing spondylitis, severe osteoarthritis and prior neck injury.Surgeries: Cholecystectomy. Had hysterectomy.Medications:Voltaren Oral.Lasix Oral.Simvastatin Oral.Synthroid Oral.Xanax Oral.Percocet Oral.Allergies: AVALOX.SOCIAL HISTORY: Nonsmoker. No alcohol use.ADDITIONAL NOTESThe nursing notes have been reviewed.08:58 01/01/20XX Weight: 112.2 kg me

CaseID: OPD7251 Primary Diagnosis: R10.13, E87.20, R00.0, R74.8 Secondary Diagnosis: F10.10, Y90.8, Z90.49 E/M Level: 99285

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: Female AGE: 37DOS: 1/1/20XXTime Seen: 14:56 PM; initial patient contact. Arrived- By private vehicle. Historian- patient. No previous visits to this facility.HISTORY OF PRESENT ILLNESS:Chief complaint- ABDOMINAL PAIN. This started today and is still present. It was abrupt in onset and has been constant. It is described as pain, sharp and stabbing and it is described as located in the epigastric area and radiating (lower abdomen intermittently). At its maximum, severity described as severe. When seen in the E.D., severity described as severe. Modifying factors- Not worsened by anything. Not relieved by anything. She has had loose stools. This has occurred several times. No nausea, loss of appetite or vomiting.Similar symptoms previously: She has had similar symptoms twice previously. (With pancreatitis.).Recent medical care: The patient was seen recently and hospitalized. (PVH February and March).REVIEW OF SYSTEMS:Last normal menstrual period- 12/X/20XX. No constipation, black stools, hematemesis, difficulty with urination or pain with urination. No urinary frequency, missed periods, abnormal bleeding, bloody stools or irregular periods. No fever, headache, sore throat, blurred vision or chest pain. No difficulty breathing, cough, joint pain, skin rash or chills. No back pain. Denies current pregnancy. The patient has not had weight loss. All systems otherwise negative, except as recorded above.PAST HISTORY:Denies the following risk factors for ectopic pregnancy - current IUD and history of infertility, PID, tubal ligation and prior ectopic. Denies the following risk factors for ectopic pregnancy - elective abortion within the last two weeks.Medications:Fluoxetine HCl Oral.Furosemide Injection.Hydrochlorothiazide Oral.Ibuprofen Oral.Lisinopril Oral.Metoprolol Tartrate Oral.Nitrofu

CaseID: OPD7433 Primary Diagnosis: S02.5XXA, S50.312A, S50.311A, S80.211A, S01.511A Secondary Diagnosis: V18.0XXA, Y93.55, Y92.828, W01.0XXA E/M Level: 99282

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: FemaleAGE: 10DOS: 1/1/20XXCHIEF COMPLAINT: Fell off bicycle.HISTORY OF PRESENT ILLNESS: This is a 10-year-old female who was riding her bicycle down a hill and slipped in some oil. She fell, sustaining several injuries. The patient struck her face and fractured her right upper incisor and sustained some lacerations to her lower lip as well. She was wearing a helmet. The patient had no loss of consciousness. She has abrasions to her elbows and a larger abrasion to her right knee. She has no neck pain. The patient has no back or chest pain.PAST MEDICAL HISTORY: Unremarkable.MEDICATIONS: The patient is on no medications.ALLERGIES: NO KNOWN DRUG ALLERGIES. IMMUNIZATIONS: The patient's last tetanus immunization was just about 5 years ago.PHYSICAL EXAMINATION: GENERAL: The patient is awake, alert in no acute distress, afebrile. VITAL SIGNS: Normal. HEENT: Pupils equal, round and reactive to light. Extraocular movements are intact. The patient has a chip of the tip of her right upper incisor. She has a small laceration to the mucosal surface of the left side of her lower lip. No jaw tenderness. There is good dental occlusion. NECK: Supple, non tender. Full range of motion. LUNGS: Clear. COR: Regular rate and rhythm without murmur. ABDOMEN: Non tender. BACK: Non tender. EXTREMITIES: The patient has a fairly large abrasion over her right knee but no bony tenderness and good range of motion. She has superficial abrasions over both elbows. NEURO: The patient is alert and oriented x3. Normal motor and sensory function. Normal speech, affect and gait. TREATMENT: The patient's abrasions were cleansed and had Lidocaine applied.ASSESSMENT1. Multiple abrasions both elbows, right knee2. Tooth fracture.3. Small lip laceration of left lower no foreign bodiesPLAN:1. The patient is to have the wounds

CaseID: OPD7239 Primary Diagnosis: S06.0X1A Secondary Diagnosis: W21.07XA, Y93.64, Y92.320 E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: MALE AGE: 40DOS: 01/01/20XXArrived- By private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESS: Chief Complaint- INJURY TO HEAD. The injury occurred last night.The patient sustained a blow. Occurred at an Baseball field. Pt was struck by a soft ball which hit him on the first hop on the left frontal temporal area. Pt fell to the ground and had possible LOC for 1 min. Pt continued to play afterwards, had headache overnight.The patient complains of mild pain. The patient sustained a blow to the head. The patient had loss of consciousness (1 - 2 minutes). No neck pain.REVIEW OF SYSTEMS: No numbness, hearing loss, nausea, chest pain or depression. No weakness, loss of vision, vomiting, difficulty breathing or bladder dysfunction. No laceration or fever. Has not recently been ill. All systems otherwise negative, except as recorded above.PAST HISTORY: Other disease. No history of heart disease, lung disease, renal disease, hypertension or neurological disease. No history of GI disease or diabetes mellitus. Tetanus immunization status is up-to-date.SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.ADDITIONAL NOTES: The nursing notes have been reviewed.Weight: 89.9 kg measured. Height: 72 inches Per Patient. BMI: 26.9.PHYSICAL EXAM:Appearance: Alert. No acute distress. (BP: 146/74 sitting R arm auto (reg adult cuff). HR: 58 (regular, bradycardic and strong). RR: 16 (regular, unlabored and normal). Temp: 97.6 temporal. O2 saturation: 98 % room air. Alert. eyes open spontaneously; best verbal response- oriented x 4; best motor response- obeys commands.Head: No swelling of head. No Battle's sign or raccoon eyes. Left temple: mild tenderness and small abrasion of the upper anterior aspect of the left temple. No erythema, swelling, laceration, ecchymosis or puncture wound. No forei

CaseID: OPD7256 Primary Diagnosis: T40.601A Secondary Diagnosis: F10.929, Y90.6, F14.10, F12.10, F17.200 CPT: E/M Level: 99285

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: MaleAGE: 49DOS: 1/1/20XXTime Seen: 20:01Arrived- By ambulance. Historian- patient and EMS personnel. Note: Previous visits to this facility for similar complaints.HISTORY OF PRESENT ILLNESSChief Complaint- DRUG OVERDOSE, ACCIDENTAL INGESTION and INTOXICATION. This occurred today. No toxic symptoms present. Multiple drugs taken (opiates). Rescue was likely for this event. Alcohol consumption also. The symptoms are described as moderate. No suicidal thoughts. (found unresponsive by mom, ems called).Similar symptoms previously: He has had similar symptoms several times previously.Recent medical care: Not recently seen/assessed.Prehospital Treatment: EMS treatment PTA verbally communicated. IV access #1. Pulse oximeter applied. NARCAN 0.4 mg X2 IVP.REVIEW OF SYSTEMSNo headache, dizziness, weakness, chest pain or palpitations. No abdominal pain, vomiting, diarrhea, black stools or fever. No sore throat, cough, difficulty breathing, difficulty with urination or skin rash. No enlarged lymph nodes. All systems otherwise negative, except as recorded above.PAST HISTORY: Type C hepatitis. Schizophrenia.Medications:Ibuprofen Oral.Allergies:Bee sting.SOCIAL HISTORY: Current smoker. Alcohol use. Last drink was just prior to arrival. History of drug use: Recently used drugs. Under influence of alcohol and drugs in ED. Has place to stay (house lives w/ mom).ADDITIONAL NOTES: The nursing notes have been reviewed.PHYSICAL EXAMAppearance: Alert. Oxygen being administered by nasal cannula. IV present X 1. EKG monitor and O2 sat monitor on the patient. The patient appears intoxicated and has ETOH on breath. (repeat bp by me 110 sys).Vital Signs: Have been reviewed and do not appear to be correct. Heart rate normal. Respiratory rate normal. Temperature normal. Oxygen saturation normal. (BP: 76 / 58 L

CaseID: OPD7255 Primary Diagnosis: M54.6 Secondary Diagnosis: R07.9, M47.814, I44.0, W18.49XA, W22.09XA, Y92.009 CPT: 93010, 93010-76 E/M Level: 99285-25

MEDICAL RECORD EMERGENCY DEPARTMENTSEX: MaleAGE: 84DOS: 1/1/20XXTime Seen: 711 bed 3.Arrived- By private vehicle. Historian- patient. Patient does not have a primary care physician.HISTORY OF PRESENT ILLNESSChief Complaint: BACK PAIN. Onset was yesterday and it is still present. It was abrupt in onset. It is described as being in the area of the left posterior shoulder, left scapula, left side of the upper thoracic spine, upper thoracic spine and left side of the mid-thoracic spine. It is described as being in the area of the mid thoracic spine, right side of the upper thoracic spine, right side of the mid-thoracic spine, right posterior shoulder and right scapula. It is described as being in the left interscapular area, interscapular area and right interscapular area. It is described as radiating to the right upper extremity and to the left upper extremity. The quality is noted to be pain. Modifying factors (worsened by everything).Associated symptoms - No bladder dysfunction, bowel dysfunction, sensory loss or motor loss.Patient notes a recent injury (yesterday). Mechanism of injury- he, slipped on wet floor, caught himself but hit back on wall. Occurred at home. Patient denies injury to the head or chest. No other injury.Similar symptoms previously: None.Recent medical care: Not recently seen/assessed.REVIEW OF SYSTEMSNo fever, chills, eye discomfort, headache or depression. No sore throat, cough, difficulty breathing, chest pain or skin rash. No abdominal pain, nausea, vomiting, diarrhea or black stools. No difficulty with urination, urinary frequency or hematuria. All systems otherwise negative, except as recorded above.PAST HISTORY: Negative. See nurses notes. generally healthy.Risk factors for neck injury- age over 40.Additional Problems: no known problems.Medications: None.Allergies: No Known Drug Allergy.SOCIA

CaseID: OPD7210 Primary Diagnosis: R10.84, R11.0 E/M Level: 99284

MEDICAL RECORD EMERGENCY DEPARTMENTSex: F AGE: 63DOS: 1/1/20XXCHIEF COMPLAINT: Abdominal pain, onset one week ago, getting better, then escalating for the past 2 days.HISTORY OF PRESENT ILLNESS: This is a female who has the above complaint with nausea and pain around her umbilicus. She states that it also seems to radiate into the right upper quadrant. Food makes no difference for her discomfort. She states that it is better with sitting and worse to moving around. The pain is generally becoming more constant. It is kind of a deep ache. There is slight nausea and some very mild prior diarrhea. There has not been any vomiting. No bloody diarrhea. No dysuria, urgency, frequency. No headache, arthralgia, congestion, back pain, heartburn, chest pain, palpitations, cough, dyspnea, and the rest of her pertinent review of systems for HPI are negative and noncontributory.ALLERGIES: None.MEDICATIONS: Valsartan.PAST MEDICAL HISTORY: GERD.SURGICAL HISTORY: A hysterectomy.PHYSICAL EXAMINATION: VITAL SIGNS: Initially blood pressure elevated at 228/105. This is rechecked. She has become more normotensive. Heart rate is 64. Respirations 20. Temperature is 96.4. O2 sat on room air is 95%. GENERAL: This is a well-developed, well-nourished 111-kg female who is in mild discomfort. Moves about easily on the gurney and is nontoxic. HEENT: Eyes - PERRLA. Nares patent. Oropharynx is clear. NECK: Supple without adenopathy or nuchal rigidity. CHEST: Clear to auscultation. There is no CVA tenderness. HEART: Regular rhythm without murmur. Pulses 2+. There is no cyanosis or peripheral edema. ABDOMEN: Soft with normoactive bowel sounds. No hepatosplenomegaly. She has tenderness to deep palpation in the periumbilical region. No guarding, rebound, or mass. INTEGUMENT: Pink, warm, dry, and without exanthem. EXTREMITIES: Moves all without difficulty.C

CaseID: OPD7214 Primary Diagnosis: K70.11 Secondary Diagnosis: F10.10, F17.210 E/M Level: 99285

MEDICAL RECORD EMERGENCY DEPARTMENTSex: M AGE: 50DOS: 1/1/20XXCHIEF COMPLAINT: Jaundice.HISTORY OF PRESENT ILLNESS: This is a male with history of abdominal pain and bloating as well as mild chest pain, difficulty with urination, tenesmus, mild nausea, and poor appetite that has been ongoing and progressively worsening over the past week. He has been having some dry heaving with this. He has been having waxing and waning abdominal pain that he describes as being in the lower portion of his abdomen and was worse yesterday. It is somewhat improved today. He has been having some loose stools, more than his normal. He does feel that his symptoms are progressively worsening. He does have worsening symptoms lying down and feels that he has a hard time catching his breath as a result. He has had chills and a fever up to 100. He went to the store to get some milk today when the clerk told him that he looked extremely yellow and thought he should go to the doctor to get seen. He denies any history of this in the past. He does admit to drinking a 6-pack of beer a day. He denies any history of hepatitis. Denies any postprandial problems or pain but has not really had an appetite. He has not taken anything particularly for this.PAST MEDICAL HISTORY: Chronic back pain.PAST SURGICAL HISTORY: Lumbar fusion.MEDICATIONS:Acetaminophen/hydrocodone.Temazepam.Omeprazole.ALLERGIES: None.SOCIAL HISTORY: He smokes a pack a day and has drunk a 6-pack of beer per day consistently for the past month.FAMILY HISTORY: No known history of gallbladder disease.REVIEW OF SYSTEMS: As above, otherwise all other systems reviewed and negativePHYSICAL EXAM: GENERAL APPEARANCE: Markedly jaundiced-appearing male, resting quietly in no apparent distress. PSYCH: He is alert and oriented x4. VITAL SIGNS: Temperature 99. Pulse 111. Respiratory rate of 20. O2 sat

CaseID: OPD7493 Primary Diagnosis: L72.3, L70.9 E/M Level: 99212

MEDICAL RECORD 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.PAST 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 Air. BP Cuff Size: adult.ROS: None Recorded.PHYSICAL EXAM: Patient is a female.BASIC CARDIO PE:HEENT: normal thyroid, no bruit, and JVP < 6.Lungs: clear to auscultation.Cardio: no murmurs or gallops and S1 and S2 normal, and non-displaced apical impulse.Abdomen: non-tender or distended; no bruit, hepatomegaly, or splenomegaly; and soft and normal bowel sounds. Extremities: no edema and pulses 2+.CONSTITUTIONAL: General Appearance: healthy-appearing, well-nourished, and well-developed. Mental Status Findings: normal orientation. Mood: quiet and happy. Affect: normal.SKIN: Scalp: Sebaceous cyst (1 mm in front of ear). Cheeks: acne cheeks. Nose: clear and normal nose. Chin: clear and normal chin. Neck: clear and normal neck. Chest: clear and normal chest. Back: clear and normal back: Upper Arms: clear and normal upper arms. Left Leg: Normal. Right Leg: normal. Left Arm: normal. Right Arm: normal.ASSESSMENT/PLAN:1. Sebaceous CYST, Scalp2. ACNE cheeksRETURN TO OFFICE: As needed.John Jones, MDElectronica

CaseID: OPD7062 Primary Diagnosis: S43.014A Secondary Diagnosis: S01.111A, N39.0, W01.0XXA, Y92.009 CPT: 23650-RT, 12011-XS-RT, 71045-26 E/M Level: 99285-57

MEDICAL RECORD Emergency Department Report Insurance: MedicareSex: FAGE: 93DOS: 01/01/20XXTime Seen: 05:08Arrived- By ambulance. Historian- patient and EMS personnel.HISTORY OF PRESENT ILLNESSChief Complaint- FALL. Location of injuries- head and right shoulder. The injury occurred just prior to arrival.Tripped and fell in the hallway. Occurred at her private residential home.The patient complains of severe pain. The patient sustained a blow to the head. No neck pain, loss of consciousness or seizure. Not dazed.REVIEW OF SYSTEMS: The patient sustained skin laceration to the face. No numbness, dizziness, loss of vision, hearing loss or chest pain. No difficulty breathing, weakness, headache, nausea or vomiting. All systems otherwise negative, except as recorded above.PAST HISTORY: Risk factors for neck injury- age over 40. Denies the following risk factors for neck injury - history of ankylosing spondylitis, severe osteoarthritis and prior neck injury.Medications: Toprol XL Oral.Allergies: NKDA.SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.ADDITIONAL NOTES: The nursing notes have been reviewed.05:09 01/01/20XX Weight: 62.6 kg stated. --05:09 Kristey R., RN.PHYSICAL EXAMAppearance: Alert. Oriented X3. No acute distress. (05:25. HR: 59 regular. RR: 22 regular. Temp: 98.5. --05:25 Kristey R., RN. 05:09 01/01/20XX Weight: 62.6 kg stated. --05:09 Kristey R., RN.).Vital Signs: Have been reviewed.Head: No Battle's sign or raccoon eyes.Eyes: Pupils equal, round and reactive to light. EOM intact. Right periorbital area: mild tenderness and swelling, small ecchymosis and 2.0 cm laceration of the lateral aspect of the periorbital area. No deformity. No entrapment of extraocular muscles or gaze palsy.ENT: No dental injury. Pharynx normal. Right ear: No hemotympanum. Left ear: No hemotympanum.Neck: Painless ROM. Non-tender.CV

CaseID: OPD7112 Primary Diagnosis: R10.2 Secondary Diagnosis: Z33.1 E/M Level: 99284

MEDICAL RECORD Emergency Department ReportAGE: 30Sex: FDOS: 1/1/20XXArrived- By private vehicle. Historian- patient and family.HISTORY OF PRESENT ILLNESSChief Complaint: PELVIC PAIN. This started today and still present. The symptoms are described as mild.The patient has had mild, intermittent, dull, aching supra pubic and left-sided pelvic pain. No vaginal discharge or bleeding or fever. She missed her last 2 periods. No abnormal bleeding, vaginal discharge, vaginal itching, genital lesions or pain with urination. No urinary frequency, urgency of urination or hematuria.Sexually active. Currently pregnant. Receiving prenatal care.Patient has not had Little ilar symptoms previously.Recent medical care: The patient was seen recently at another facility in a clinic. (Pt is followed per Andrea Jones OB ; has appt next week.).REVIEW OF SYSTEMS: The patient has had nausea. No vomiting, diarrhea, black stools, headache or fever. No chills, anorexia, eye discomfort, sore throat or cough. No difficulty breathing, chest pain, skin rash, enlarged lymph nodes or joint pain. All systems otherwise negative, except as recorded above.PAST HISTORY: Other disease. (Pt is O pos.). Has not had a pelvic infection. No history of sexually transmitted disease, ectopic pregnancy, ovarian cyst, endometriosis or heart disease. No history of lung disease, renal disease, hypertension, neurological disease or GI disease. No history of diabetes mellitus.Denies the following risk factors for ectopic pregnancy - current IUD, history of PID, tubal ligation and prior ectopic and elective abortion within the last two weeks.Surgeries: No history of previous surgery. No history of tubal ligation or hysterectomy.Medications:Zofran Oral.Prenatal Vitamins Oral.Allergies:NKDA.SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use. No recent travel. Is a local r

CaseID: OPD7063 Primary Diagnosis: S50.812A, S50.12XA Secondary Diagnosis: W03.XXXA, Y92.019 E/M Level: 99283

MEDICAL RECORD Emergency Department ReportAGE: 32 Sex: MDOS: 01/01/20XXCHIEF COMPLAINT: Left arm pain.HPI: This is a male man who fell on his left arm. This happened about 2 hours ago. He was playing with his kids, at his single family private home, and tripped over one of them and fell. He has some numbness in his fingers at baseline due to a history of frostbite. However, he has no new paresthesias. He did not take any medication for it. He denies any other trauma including head trauma. He denies loss of consciousness.PAST MEDICAL HISTORY: Irritable bowel syndrome.PAST SURGICAL HISTORY: Hernia repair.MEDICATIONS: None.ALLERGIES: PENICILLIN.SOCIAL HISTORY: The patient does not smoke or drink alcohol. He denies any other drugs.REVIEW OF SYSTEMS: As per the HPI, otherwise unremarkable.PHYSICAL EXAM: VITAL SIGNS: Temperature 98.6, pulse 103, respiratory rate 16, pulse oximetry 96% on room air, blood pressure 138/82. GENERAL: He is a well-developed, well-nourished, thin man appearing his stated age in no acute distress. RESPIRATORY: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. GI: Soft, nontender, nondistended with normal bowel sounds. EXTREMITIES: Patient has an abrasion on the medial side of his left forearm. He has some tenderness in the distal forearm and over the right metacarpal. There is no snuffbox tenderness. Distally neurovascularly intact per the patients per the patient's norm. NEURO: He does not have sensation of find touch to the tip of his fingers throughout and he states this is normal for him.EMERGENCY DEPARTMENT COURSE: An x-ray of his left forearm and left hand were done, both of which were negative for any fractures or malalignment. Wounds were cleansed and antibiotic ointment and dry dressing were applied.DIAGNOSIS: Abrasion with contusion.DI

CaseID: OPD7065 Primary Diagnosis: R42 Secondary Diagnosis: I10 CPT: 93010, 93042-59 E/M Level: 99284-25

MEDICAL RECORD Emergency Department ReportAGE: 75 Sex: FDOS: 01/01/20XX Time Seen: 00:14 Arrived- By private vehicle. Historian- patient and family, using an interpreter. Note: Previous visits to this facility for similar complaints.HISTORY OF PRESENT ILLNESS:Chief Complaint: DIZZINESS. (feels shaky). This started just prior to arrival and is still present but is improving. It was abrupt in onset and has been waxing/waning (after argument w/ husband). Described as feeling light-headed. Not described as a sense of rotation, movement, falling or confusion. Not described as feeling off balance, faint or weak all over. Severity described as moderate at its maximum. When seen in the E.D., it was almost gone. Modifying factors- relieved by nothing. Not worsened by anything. No nausea, vomiting, hearing loss, tinnitus or ear pain. (emotional upset after argument w/ husband).Similar symptoms previously: She has had similar symptoms several times previously.Recent medical care: The patient was seen recently in a clinic. (N HALL).REVIEW OF SYSTEMS: The patient has had chills. No headache double vision, weakness, fainting episodes or head injury. No chest pain, palpitations, black stools, abnormal vaginal bleeding or fever. No sore throat, cough, difficulty breathing, abdominal pain or diarrhea. No difficulty with urination, skin rash or enlarged lymph nodes. No difficulty walking. All systems otherwise negative, except as recorded above. PAST HISTORY: Hypertension. Anxiety. Surgeries: C-section. Medications: BP med. Allergies: NKDA SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use. ADDITIONAL NOTES: The nursing notes have been reviewed. PHYSICAL EXAM: Appearance: Alert. Oxygen being administered by nasal cannula. IV present X 1. EKG monitor and O2 sat monitor on the patient. Anxious. The patient is cooperative, appears frail

CaseID: OPD7074 Primary Diagnosis: S39.013A Secondary Diagnosis: M77.11 E/M Level: 99283

MEDICAL RECORD Emergency Department ReportCHIEF COMPLAINT: Left hip pain.HISTORY OF PRESENT ILLNESS: THe patient had been jogging 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 housekeeper for our facility.REVIEW OF SYSTEMS: As per the HPI; otherwise unremarkable.PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.7, pulse 80, respiratory rate 18, pulse oximetry 98% on room air, blood pressure 117/71. GENERAL: He is a well-developed, well-nourished pleasant man appearing his stated age in no acute distress. NECK: Supple, nontender. No lymphadenopathy. RESPIRATORY: Clear to auscultation bilaterally. CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops or rubs. GI: Soft, nontender, nondistended with normal bowel sounds. The patient does have some tenderness to the iliac crest on the left. No contusion or trauma is noted. EXTREMITIES: No cyanosis, clubbing or edema. No signs of deformity or trauma. He has no tenderness in his elbow, wrist or hand. His Tinel sign is negative. He has full range of motion.EMERGENCY DEPARTMENT COURSE: A pelvis x-ray was done to rule out any bone cyst or lesion that could be causing his pain and

CaseID: OPD7031 Primary Diagnosis: R32, G40.909 CPT: 72148-26

MEDICAL RECORD MOUNTAIN HOSPITAL RADIOLOGY REPORTSex: MaleAGE: 7DATE OF EXAM: 1/01/20XXPHYSICIAN(S): M.D.PROCEDURE: MRI LUMBAR SPINE WITHOUT CONTRASTCOMPARISON: None.INDICATIONS: Frequent urinary incontinence, epilepsy, question of tethered cord.TECHNIQUE: Sagittal T1, FSE T2, STIR; axial FSE T2 images parallel to the disc spacesFINDINGS: The alignment of the lumbar vertebral body is normal. The disc spaces are maintained. The configuration of the thecal sac is normal. We identify the conus. The tip of the conus is at level T11-T12, it's in normal position. There are no signs of any intraaxial masses. No signs of any meningomyeloceles. There is no underlying scoliosis. No other signs to suggest a tethered cord.CONCLUSION:1. NORMAL STUDY.Electronically signed by 1/1/20XX

CaseID: OPD7238 Primary Diagnosis: R11.10 E/M Level: 99282

MEDICAL RECORD Emergency Department ReportSex: M AGE: 8 DOB: 1/1/20xxDOS: 01/01/20XXTime Seen: 09:54 Arrived- By private vehicle. Historian- mother.HISTORY OF PRESENT ILLNESS:Chief 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 a clinic. (Told he had virus.).REVIEW OF SYSTEMS: The patient has had a nasal discharge and nasal congestion. No ear pain, sore throat, eye irritation or eye discharge or difficulty with urination. No cough, difficulty breathing, headache, seizure or skin rash. No back pain. Has not been pulling at ears. All systems otherwise negative, except as recorded above.PAST HISTORY: Negative.Surgeries: No history of previous surgery.Additional Surgeries: no known surgeries.Immunization status is up-to-date.Medications: None.Allergies: No Known Drug Allergy.SOCIAL HISTORY: Nonsmoker. Does not attend daycare.ADDITIONAL NOTES: The nursing notes have been reviewed.09:35 01/01/20XX Weight: 10.1 kg measured. --09:36 Kyley J., R.N.PHYSICAL EXAM: Appearance: Alert. No acute distress. Attentive. Smiles. The patient makes eye contact. Active. Playful. (Pushing stroller around exam room).Vital Signs: Have b

CaseID: OPD7085 Primary Diagnosis: Z18.10 E/M Level: 99283

MEDICAL RECORD Emergency Department ReportSex: MAGE: 81DOS: 01/01/20XXTime Seen: 1329.Arrived- By private vehicle. Historian- patient and family.HISTORY OF PRESENT ILLNESSChief Complaint- Injury to the left hand and left thumb (possible metal FB). The injury happened possibly 3 months ago while the patient was in the hospital. This was not an incised wound. Thinks there is a broken needle in the thumb. Patient is experiencing mild pain. No other injury.REVIEW OF SYSTEMSThe patient has had tingling of the left index finger (mild). No swelling, weakness or skin laceration. All systems otherwise negative, except as recorded above.PAST HISTORYThe patient's dominant hand is the right.Surgeries: History of previous surgery. Coronary artery bypass graft surgery. Right and left knee prosthesis.Medications:Aspirin.Crestor Oral.Diovan HCT Oral.Norvasc Oral.Toprol XL Oral.Allergies:Cephalexin.SOCIAL HISTORYNonsmoker. No alcohol use.ADDITIONAL NOTESThe nursing notes have been reviewed.Weight: 103.1 kg measured.PHYSICAL EXAMAppearance: Alert. Oriented X3. No acute distress.Vital Signs: Normal.CVS: Normal heart rate and rhythm. Heart sounds normal.Respiratory: No respiratory distress. Breath sounds normal.Skin: Skin warm and dry. Skin intact.Extremities: Dorsal left hand: mild tenderness and suspected foreign body (ulnar border of the left thumb just prox to MPJ). No erythema or swelling. No wrist injury. Hand and wrist exam otherwise negative. Extremities otherwise negative.Neuro, Vascular and Tendons: Vascular status intact. Decreased light touch sensation (left index finger). Tendon function intact.Neuro: Oriented X 3. Sensory deficit present (left index finger pad). Altered sensation to light touch MISSING_POSTAMBLE.LABS, X-RAYS, AND EKGX-Rays: Left hand and thumbPROGRESS AND PROCEDURESCourse of Care: Pt with definite metallic F

CaseID: OPD7444 Primary Diagnosis: Z01.419 Secondary Diagnosis: N39.3, Z12.72 E/M Level: 99396

MEDICAL RECORD MEDICAL RECORDFamily Practice USADr. John JonesSEX: FEMALE AGE: 54 CC: annual exam, urinary incontinence S: This is a 54-year-old female, gravida 1, para 1, who is here for her annual examination. She reports urinary incontinence. She will wear a light pad all day due to urine leakage when she coughs, laughs, sneezes, etc. It is not a significant amount of urine leakage but she wears the pad because she does not know when it will happen. She reports significant irritation from wearing pads all day and gets yeast infections. She does not desire any surgery for her urinary incontinence. She reports that family members have had bad outcomes after urinary incontinence surgery. I did discuss with the patient lifestyle changes including decreasing caffeine, decreasing drinking large amounts of fluid, and timed voiding as well as Kegel exercising. She expressed understanding. We also discussed pelvic floor physical therapy as a potential option for treatment for urinary incontinence as she desires avoiding surgery. She is very interested in trying physical therapy at this time. Her mammogram in April was within normal limits. She had a colonoscopy in 20XX. Her menses are every one to two months with seven days of normal flow. She denies intermenstrual or postcoital bleeding. She has no dyspareunia or dysmenorrhea. Her past medical history and surgical history are reviewed. ROS: Constitutional: negative; HEENT: negative; Skin: negative; Respiratory: negative; Cardiovascular: negative; Musculoskeletal: negative; Neurologic/Psychiatric: negative; Endocrine: negative; Heme/Immunologic: negative; Gastrointestinal: negative; Genitourinary; stress urinary incontinence; Breasts: negative, with no tenderness. O:Vitals: BP: 128/72; Weight: 133 lbs; General: This is a well-developed, well-nourished female in no acute dist

CaseID: OPD7440 Primary Diagnosis: M25.511 E/M Level: 99203

MEDICAL RECORD MEDICAL RECORDOFFICE - NEWDr. John SmithSEX: MALE Age: 16 DOS: 1/1/20XX CC: Pain in right shoulder Impression: probable SLAP lesion of right shoulder Plan: MRI arthrogram of the shoulder and follow up again after the scan. Patient is a 16-year-old boy who says that about 3 weeks ago he injured his shoulder while playing football. He says he fell onto the shoulder and ever since then he has noted popping sensations in certain positions of the arm and these are quite painful. He says he is having difficulty throwing with that arm. He also notes that he has never had any history of dislocation of the shoulder and does not feel any symptoms suggestive of instability of the shoulder. No specific treatment for his pain. He did go to the ER at Hospital where an x-ray was taken and was reassured about his symptoms. He was advised if not better to see Primary Care Physician. Past Medical History: no chronic illnesses. Past Surgical History: no previous operations Allergies: none Medications: none Social History: The patient does not smoke, drink alcohol or use illegal drugs Family History: Hypertension and kidney disease ROS: HEENT, GI, GU, cardiorespiratory, neurological, endocrine and constitutional systems were reviewed, and these are negative. PHYSICAL EXAMINATION: Vital Signs: Pulse: 79; Respirations: 19; Blood pressure: 113/79; Temperature: 98.6 F°; Weight: 170 lbs; Height: 5'6". GENERAL: He is a well-nourished African-American boy sitting on the couch in no acute distress, well oriented to time, place, and person. HEENT: head is atraumatic and normocephalic. Mucous membranes are moist. NECK: supple and nontender. HEART: S1 and S2. LUNG: clear. ABDOMEN: soft and nontender. Extremity Exam: Right shoulder examination shows that he preserves full range of motion with no signs of impingement. There is palpabl

CaseID: OPD7286 Primary Diagnosis: I10, E78.00, R05.9 E/M Level: 99214

MEDICAL RECORD OFFICE - ESTABLISHEDCARDIOLOGYSEX: MaleAGE: 63Established PatientDate: 01/01/20XXCHIEF CONCERN: He is here for lab results.PROBLEM LIST1. 63-yo with hypertension, with suboptimal recent control.2. Hyperlipidemia on treatment3. Abnormal stress echo consistent with limited anteroseptal ischemia, asymptomatic.ALLERGIES: NSAIDs (GI bleed), ACE cough.MEDICATIONSAtenolol 25 mg b.i.d.Atorvastatin 40 mg dailyKCl 16 mEq per dayFlomax 0.4mg q. hsBenicar 40 mg q.d.HCTZ 125 mg q.d.INTERVAL HISTORYBlood pressure is significantly improved on above medication. He continues to have a frequent dry cough, which he reports is a tickle in his throat. He has history of an ACE cough. Must consider Benicar versus postnasal drip and localized allergies. He has noted minor lethargy lately, which could also be allergies. He has had no myositis on Lipitor.Labs (01/01/20XX) show:1. Cholesterol 138, triglycerides 95, HDL 53, LDL 76.2. CMP is unremarkable.PHYSICAL EXAMINATIONVITAL SIGNS: Weight 182 lbs. BP 122/64 in the left arm, pulse 71 and regular, oxygen saturation 93% on room air.CONSTITUTIONAL: In no acute distress.HEENY: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis. No cervical lymphadenopathy. Thyroid unremarkable.RESPIRATORY: Frequent dry cough is noted. Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest has normal contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 are normal. No murmur, clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.NEURO

CaseID: OPD7287 Primary Diagnosis: Z51.81, I49.3, I10 E/M Level: 99213

MEDICAL RECORD OFFICE - ESTABLISHEDCARDIOLOGYSEX: MaleAGE: 77Date: 01/01/20XXCHIEF CONCERN: He is here for medication check.PROBLEM LIST1. Single-vessel coronary artery disease with mid-distal LAD stent (0X/01/20XX).2. Cardiomyopathy, ejection fraction 40%.3. Left bundle branch block.4. Hypertension.5. Mitral valve prolapse.ALLERGIES: No known drug allergies.MEDICATIONSBenicar HCT 20/12.5 mg q.d.Aspirin 81 mg q.d.Metoprolol ER 37.5 mg q.d.Plavix 75 mg q.d.INTERVAL HISTORY: At last office visit, a stress echocardiogram was equivocal for ischemia. He therefore proceeded to a nuclear stress test that showed no evidence of ischemia. Specifically, there was normal perfusion to inferior wall. His metoprolol was increased to 37.5 mg q.d. He has had no lightheadedness, dizziness or palpitations. No chest pain or shortness of breath. Blood pressure is well-controlled. He has returned to his previous level of exercise, which includes riding his bicycle 15 to 20 minutes daily.PHYSICAL EXAMINATIONVITAL SIGNS: Weight 140 lbs. BP 122/62 in the left arm, pulse 62 and regular, oxygen saturation 96% on room air.CONSTITUTIONAL: Respirations even and unlabored. Skin pink, warm and dry. He is in no distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. Noadventitious sounds. Chest has normal contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 are normal. No murmur, clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.SKIN: Right groin puncture site is well-healed. Skin is otherwise pink, warm, dry a

CaseID: OPD7480 Primary Diagnosis: E87.6, M51.360 Secondary Diagnosis: Z98.890 E/M Level: 99213

MEDICAL RECORD OFFICE - ESTABLISHEDSEX: 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 TABLYRICA 50 MG CAPPAROXETINE 10 MG TABSIMVASTIN 10 MG TABTRAZODONE 100 MG TABVERAPAMIL ER 240 MG TABVACCINES: Vaccines Not Reviewed (last reviewed 2/1/20XX). Influenza - 20XXSOCIAL HISTORY: Social History Not Reviewed (last reviewed 2/1/20XX). Family Practice: Alcohol Intake: none. Caffeine Intake: occasional. Illicit Drugs: none. Marital Status: single. Non-smoker. PAST MEDICAL HISTORY: Past Medical History Not Reviewed (last reviewed 2/1/20XX). Anxiety Disorder: Y. COPD: Y. FAMILY HISTORY: Family History Not Reviewed (last reviewed 2/1/20XX)SURGICAL HISTORY: Surgical History Not Reviewed (last reviewed 2/1/20XX).• Spinal Surgery - 20XX• Knee Surgery - 20XX• Hysterectomy - 19XX - partial.• Tonsillectomy and/or Adenoidectomy - 19XXPatient is a female - VITALS: Height: 5'4". Weight: 138 lbs 4 oz. BMI: 23.7. BP: 124/72 sitting R arm. Pulse: 87 bpm regular. RR: 16. O2Sat: 95%. T: 97.8°.ROS: None Recor

CaseID: OPD7517 Primary Diagnosis: R94.31, R00.0, I10, E78.5, I49.1 Secondary Diagnosis: Z86.73 CPT: 93350, 93325 E/M Level: 99214-25

MEDICAL RECORD OFFICE - ESTABLISHEDSEX: FemaleAGE: 59Date: 01/01/20XXPROBLEM LIST:1. Patient is a female with recurrent rapid heart rate.2. Several years hypertension.3. Lacunar infarct associated with noncompliance with medication and accelerated hypertension.4. Hyperlipidemia on Pravastatin.5. EKG abnormality. Borderline long QT syndrome.6. Positive family history of long QT syndrome.ALLERGIES: No known drug allergies.MEDICATIONS:Lisinopril 10 mg q.d.Pravastatin 40 mg q.d.Abilify 7.5 mg dailyBupropion SR 150 mg b.i.d.Adderall ER 30 mg q.d.Gabapentin 300 mg p.r.n.Hydrocodone 4 tablets mg q.d. (shoulder and low back pain)Hydroxyzine 100 mg p.r.n.Zolpidem 15 mg h.s. p.r.n.INTERVAL HISTORY:The patient underwent a cardiac test today which showed:1. No evidence of ischemia at a moderate workload.2. No exercise-induced arrhythmia or exercise-induced QT prolongation.Holter monitor (12/20/20XX) shows:1. Sinus tachycardia to 110.2. Sleeping heart rate of 60 per minute.3. Occasional PACs.Echo (01/01/20XX) shows:1. Early septal hypertrophy.2. She has a hyperkinetic left ventricle.Labs (01/01/20XX) shows:1. Fasting lipids: Cholesterol 350, triglycerides 315, HDL 68, and LDL calculated 219 milligrams percent.2. TSH is not available.Oxygen desaturation less 88% of 20 minutes and 56 seconds. Lowest level was to 74%, as above.PHYSICAL EXAMINATIONVITAL SIGNS: BP 100/80, pulse, oxygen saturation 98°/s on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: Fundi unremarkable. No A-V nicking. No hemorrhages. No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis. No cervical lymphadenopathy. Thyroid unremarkable.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally with extensive bibasilar expiratory rhonchi. Chest has normal contour.CARDIOVASCULAR: PMI normal.

CaseID: OPD7294 Primary Diagnosis: I10, G47.30 Secondary Diagnosis: F17.210, Z99.89, Z95.810 E/M Level: 99214

MEDICAL RECORD OFFICE - ESTABLISHEDSEX: Male AGE: 52Date: 01/01/20XXCHIEF CONCERN: He is here for follow-up cardio managementPROBLEM LIST:1. Dilated cardiomyopathy, ejection fraction 30%.2. Two years S/P prophylactic AICD.3. Refractory hypertension.4. Sleep apnea managed with BIPAP supplemental oxygen night only5. Abdominal aortic aneurysm measured at 4.6 cm.6. 20 pack-year history of smoking, ongoing 1 pack per day.7. Obesity.ALLERGIES: Penicillin. He gets generalized body aching with triamterene/HCTZ.MEDICATIONS:Amlodipine 10 mg b.i.d.Lisinopril 20 mg b.i.d.Pravastatin 20 mg q.d.Carvedilol 12.5 mg b.i.d.Oxygen 3 liters (BIPAP)Aldactone 25 mg q.d.INTERVAL HISTORY: Due to miscommunication, the patient was taking his Coreg one time a day only. His CPAP has recently been replaced with BIPAP and pressure increased. He now feels it is fully effective and overall feels better. His weight is down seven pounds due to better diet. He does continue to work at a very stressful job and is not willing to give up cigarette smoking at this time. He has had no chest pain. His breathing is stable. No lightheadedness, dizziness or palpitations.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 294 lbs, BP 152/86 in the left arm, pulse 69 and regular, oxygen saturation 91% on room air.CONSTITUTIONAL: Obese Caucasian male.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest has normal contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 and normal. No murmur clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No masses or tendernes

CaseID: OPD7309 Primary Diagnosis: I11.9 Secondary Diagnosis: G47.30, I25.2, Z95.5, Z99.89 E/M Level: 99214

MEDICAL RECORD OFFICE - ESTABLISHEDSEX: MaleAGE: 70Date: 01/01/20XXCHIEF COMPLAINT: He is here for six-month check and ekg and echocardiogram results (done last week.)PROBLEM LIST1. Patient is a male with anterior septal myocardial infarction with LAD stent (20XX).2. Hypertension.3. Sleep apnea, intolerant to CPAP, using oral device with adequate oxygen saturations.4. Left ventricular hypertrophy.ALLERGIES: Penicillin (rash), Aldactone (azotemia), Lipitor and Lopid (hypertransaminasemia and myositis)MEDICATIONS:Coreg 37.5 mg b.i.d.Losartan 50 mg q.d.HCTZ 25 mg q.d.Fosinopril 40 mg b.i.d.Zetia 10 mg q.d.Crestor 10 mg q.d.Meloxicam 15 mg q.d.Multivitamin q.d.Vitamin C 500 mg q.d.Nitro Quick 0.4 mg p.r.n.Vitamin D3 1000 IU q.d.Calcium 600 mg q.d.B12 p.o. q.d.INTERVAL HISTORY: The patient presents today for a six-month checkup and echocardiogram results. He is using his oral device as prescribed and repeat oxygen saturation shows adequate treatment. He has had no medication problems. No chest pain, shortness of breath, lightheadedness, dizziness, accidents, illnesses or hospitalizations. He has had uncomplicated cataract surgery. His home blood pressures are 120/70 to 130/80. He does not have a routine exercise program, but walks long distances within his work environment. He is new on Meloxicam for knee arthritis, which is working well without increased blood pressure. He will occasionally take NSAIDs for back pain.EKG shows: 1. Normal sinus rhythm at 65 b.p.m. with no ST changes or arrhythmia.Echocardiogram shows:1. Ejection fraction of 55-60%.2. Mild aortic insufficiency.3. Trace mitral regurgitation.4. Aortic sclerosis without stenosis.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 179-1/2 lbs, BP 126/72 in the left, pulse 86 and regular,oxygen saturation 93% on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No x

CaseID: OPD7474 Primary Diagnosis: M16.0 CPT: 73522 E/M Level: 99204-25

MEDICAL RECORD 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 is a pleasant but obese female. 5' tall, 205 pounds. Her leg lengths are symmetric. She has a varus alignment of both knees with contractures due to OA of the knees. Her right hip is slightly tender. Her range of motion is very restricted, 85 of flexion, 0 IR, ER 25 degrees, abduction 30 degrees and extension 5 degrees from neutral. Her left hip has severely restricted motion with 90 degrees of flexion, IR o, ER 40 degrees and abduction 40 degrees. Her gait is antalgic.IMAGING STUDIESX-rays obtained in the office, a one view AP pelvis and two view AP Bilateral hips, show advanced bone on bone osteoarthritis. The left hip is bone on bone as well, but not as much osteophyte formation. DIAGNOSIS: Bilateral hip primary osteoarthritis.TREATMENT:Definitive management would be a right total hip arthroplasty. We briefly discussed the surgery. She will require medical clearance. She will return follow

CaseID: OPD7443 Primary Diagnosis: M25.311 Secondary Diagnosis: M75.41 E/M Level: 99204

MEDICAL RECORD OFFICE - NEW PATIENTDr. John JonesSEX: MALEAge 35DOS: 1/1/20XXCC: Right shoulder painHPI: A male who 18 years ago dislocated his shoulder and had a recurrent problem ultimately treated with an arthroscopic Bankart repair in 20XX. In 20XX, he was diving for a softball and dislocated his shoulder. He has been treated conservatively with physical therapy exercises. He continues to have recurrent problems with dislocation and pain in his shoulder. This is in his anterolateral shoulder and radiates into his axilla. Patient is here for shoulder pain and to establish himself as a patient.Previous Surgeries: 2 hand surgeries, hernia, and arthroscopic Bankart repair on his shoulderPast Medical History: NoneChronic Medications: NoneAllergies: No known drug allergiesSocial History: He drinks wine and uses smokeless tobacco.Review of Systems: 4 systems were, indeed, reviewed and were found to be negativePhysical Exam: He has full range of motion of his shoulder except for lacking 20° of internal rotation on the right shoulder. He has pain apprehension and some instability to anterior translation of his shoulder. He does have mild impingement syndrome with a positive Neer's. Negative Speed, Jorgensen, and Spurling test. He is afebrile. His vital signs are stable. He weighs 320 lbs. Alert and Oriented X3 Respiratory: equal breathsHis past arthrogram sent to us, of his shoulder was reviewed. He has a Hill-Sachs deformity without full thickness rotator cuff tear.Right anterior shoulder instabilityRight shoulder impingementDisposition: His latest injury is degenerative. He also has impingement of his shoulder. He has failed conservative treatment. We elected to proceed with arthroscopic Bankart revision surgery for anterior shoulder instability.John Jones, MDElectronically signed by JOHN JONES, MD 1/1/20XX​

CaseID: OPD7284 Primary Diagnosis: I87.2, I97.89 Secondary Diagnosis: Z95.1 E/M Level: 99203

MEDICAL RECORD OFFICE - NEWCARDIOLOGYSex: MAge 73Consulting Physician: Robert Jones, MDReferring Physician: John Kramer, MDDate: 01/01/20XXCHIEF CONCERNNew Patient and he is here for hospital follow-up.PROBLEM LIST1. 71-yo with four-vessel CABG (LIMA/LAD. SVG to ramus, OM and PDA) on 01/01/20XX, following abnormal EKG and PVCs on routine examination.2. Five years S/P prostate cancer.3. Hyperlipidemia (LDL 147, total cholesterol 220).4. Vertigo secondary to labyrinthine disorder.ALLERGIESNo known drug allergies.MEDICATIONSAllergy nasal spray q.d.Ibuprofen 400 mg p.r.n.Diphenhydramine p.r.n.Amiodarone 200 mg b.i.d.Metoprolol tartrate 25 mg b.i.d.Lisinopril 5 mg q.d.KCl 20 mEq q.a.m.Furosemide 40 mg q.d.Crestor 20 mg q.d.Aspirin 81 mg q.d.INTERVAL HISTORYThe patient is here for hospital follow-up. Following an abnormal EKG, he had a stress echocardiogram and ultimately four-vessel bypass 45 days ago. He has had no chest wound complications, but has had significant lower extremity edema, redness and swelling. He presented to his physician's office approximately one week ago for evaluation of this and was put on an antibiotic for one week. His legs remain quite swollen, worse after sitting for 30 minutes, which he has been at this point. He and his wife report increased swelling every day and even since sitting here.He has no significant incisional pain. He remains compliant with upper extremity restrictions and has not yet begun exercise, but walks around the house. He has his pillow with him. He denies fever, sputum production or lower extremity weeping.PHYSICAL EXAMINATIONVITAL SIGNS: Weight 242 lbs. BP 114/62 in the left arm, pulse 68 and regular, oxygen saturation 94% on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, w

CaseID: OPD7206 Primary Diagnosis: M54.50, R51.9 E/M Level: 99212

MEDICAL RECORD OFFICE VISIT - ESTSex: M AGE: 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 headachePLAN: 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 worseDavid Kramer, MDElectronically signed by DAVID KRAMER, MD 1/1//20XX

CaseID: OPD7285 Primary Diagnosis: Z45.02, I10 CPT: 93289 E/M Level: 99213-25

MEDICAL RECORD OFFICE- ESTABLISHEDCARDIOLOGYSEX: MaleAGE: 83Date: 01/01/20XXCHIEF CONCERN: He is here for AICD check and five-month check.PROBLEM LIST1. 83-year-old S/P A-V sequential biventricular AICD pacemaker (0X/01/XX) following left heart catheterization that shows 50-60% LAD stenosis; otherwise normal coronary arteriogram.2. Cardiomyopathy, ejection fraction 40-45% initially, now 50-55% following BiV optimization.3. Abnormal EKG.4. Left ventricular dyssynergy associated with left bundle-branch block.5. Hypertension; controlled.6. Type 2 diabetes with borderline control.7. Hypothyroidism, on replacement treatment.ALLERGIES: No known drug allergies.MEDICATIONSL-thyroxine 50 mcg q.d.Glipizide 5 mg b.i.d.Prednisolone eyedropsMetoprolol succ 25 mg q.d.Lisinopril 10 mg q.d.Ranitidine q.d.Metformin 500 mg q.d. (pt decreased dose from 1000 mg to 500 mg on his own and is not sure if he is taking)INTERVAL HISTORY: The patient is here for a five-month check and pacemaker interrogation. He has had no chest pain or shortness of breath, lightheadedness, dizziness or syncope. He does not exercise routinely. Average home blood pressure is from 110 to 120 systolic. He is unsure about his diabetic medicines and does not measure his blood pressure at home.AICD interrogation today supervised and interpreted by me Robert Jones, MD shows:1. Battery status is good at 2.93 volts.2. He is atrial pacing 7% and BiV pacing 100%.3. He had one high ventricular rate of 180 b.p.m., but lasted 2 seconds only. He was asymptomatic.PHYSICAL EXAMINATIONVITAL SIGNS: Weight 139 lbs, BP 114/68 in the left arm, pulse 73 and regular, oxygen saturation 97% on room air.CONSTITUTIONAL: He is somewhat disheveled-appearing, ambulating with a cane.HEENT: Bilateral ptosis. No xanthelasma or exophthalmos. Tongue midline. Mucous membranes moist, with no cyanosis

CaseID: OPD7488 Primary Diagnosis: B36.0 E/M Level: 99213

MEDICAL RECORD 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 History. Non-contributory.GYN History: Reviewed GYN History.OBSTETRIC HISTORY: Reviewed Obstetric History.SURGICAL HISTORY: Reviewed Surgical History.VITALS: Height: 5'8". Weight: 169 lbs. BMI: 25.7. BP: 110/60 sitting R arm. Pulse: 69 bpm regular. RR: 12. O2Sat: 98% Room Air. ROS: Patient reports no dry eyes and no vision change. She reports no difficulty hearing. She reports no sore throat. She reports no chest pain, no shortness of breath when walking, and no palpitations. She reports no cough and no wheezing. She reports no abdominal pain, no diarrhea, and not vomiting blood. She reports no jaundice and no rashes. She reports no fatigue. She reports no swollen glands and no bruising. PHYSICAL EXAM: Patient is a 26-year-old female. CONSTITUTIONAL: General Appearance: healthy-appearing, well-nourished, and well-developed. Level of Distress: NAD. Ambulation: ambulating normally.PSYCHIATRIC: Ins

CaseID: OPD6998 Primary Diagnosis: K80.50 CPT: 47562

MEDICAL RECORD OPERATIVE NOTEAGE: 35SEX: MaleDOS: 1/1/20XXPHYSICIAN: MDPREOPERATIVE DIAGNOSIS: Biliary colic.POSTOPERATIVE DIAGNOSIS: Biliary colic.OPERATIVE PROCEDURE: Laparoscopic cholecystectomy.SURGEON: MDANESTHESIA: General and local.COMPLICATIONS: None.FINDINGS: He had, of course, the normal-appearing gallbladder. There was no evidence of inguinal herniation or other diseases.INDICATIONS: The patient is a male who recently had a HIDA scan demonstrating 0% ejection fraction. He has been having severe upper abdominal pain. He now presents for cholecystectomy.DESCRIPTION OF PROCEDURE: After informed consent was obtained, the patient was brought back to the operating room, placed on operating table in supine fashion. After adequate monitors were placed, the patient was endotracheally intubated and anesthetized. Compression boots were placed. The patient's abdomen was prepped with Hibiclens soap and sterilely draped. A time-out was performed, confirming the patient and the procedure.Local anesthetic was infiltrated into the infraumbilical skin crease and the skin incision was made. A Veress needle was passed into the peritoneal cavity without difficulty and this was then inflated to a pressure of 15 mmHg using carbon dioxide. A 5-mm Optiport was then positioned, demonstrating appropriate placement. The laparoscope was then positioned and quick visualization demonstrated no obvious abnormalities. There was no evidence of inguinal hernias. Under direct vision, a 5-mm port was placed in the right side of the abdomen and an 11-mm port in the subxiphoid position. The patient was placed in reverse Trendelenburg and tilted to the left side. The gallbladder was grasped and pushed up towards the right hemidiaphragm. I was able to slowly free up the infundibulum and the cystic duct and cystic artery. I continued my dissection o

CaseID: OPD7139 Primary Diagnosis: S02.2XXA Secondary Diagnosis: M95.0, J34.2, J34.3, W16.022A, Y92.34, Y93.12 CPT: 21335, 30140-50

MEDICAL RECORD OPERATIVE REPORT AGE: 36 DOS: 1/1/20XX PHYSICIAN: J. Andrews, MD PREOPERATIVE DIAGNOSIS: Acute nasal fracture with nasal deformity and nasal septal deformities and turbinate hypertrophy. POSTOPERATIVE DIAGNOSIS: Acute nasal fracture with nasal deformity and nasal septal deformities and turbinate hypertrophy. OPERATIVE PROCEDURE: Open reduction of nasal fracture and open reduction of nasoseptal fracture and open reduction of nasoseptal fracture with bilateral submucous resection of inferior turbinates. SURGEON: J. Andrews, MD POSTOP CONDITION: Good. ANESTHESIA: General endotracheal. ESTIMATED BLOOD LOSS: Less than 30 mL. COMPLICATIONS: None. OPERATIVE FINDINGS: The patient had fractures of the nasal septum including the quadrangular cartilage, which was dislocated to the left obstructed by the nasal valve, and fractures of the vomer with large spur projecting to the right. There is enlargement of the inferior turbinates bilaterally. The patient has fractures of the nasal bone, which were partially healed with displacement of the nasal pyramid from right to left. This created elongation of the right nasal bone and depression of the left nasal bone medially. INDICATIONS FOR SURGERY: This is a male, who fractured his nose when he dove into a (public) swimming pool and hit the bottom of the pool three days ago. He had a laceration repaired at an Urgent Care Center. The nose was deformed, and he has been unable to breathe through his nose since his injury. He has no personal or family history of bleeding disorder. DESCRIPTION OF PROCEDURE: The patient was taken to the operating room and placed on the table in supine position. The patient was induced under general oral endotracheal anesthesia. After satisfactory induction of anesthesia, 1% lidocaine with 1:100,000 epinephrine was injected in the nasoseptal muco

CaseID: OPD7157 Primary Diagnosis: I83.812 CPT: 37799

MEDICAL RECORD OPERATIVE REPORTSEX: Female AGE: 43DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Varicose veins, left thigh.POSTOPERATIVE DIAGNOSIS: Varicose veins, left thigh.PROCEDURE PERFORMED: Stab phlebectomies, varicose veins, left thigh.ANESTHESIA: General.SKIN PREP: ChloraPrep.DRAINS: None.INDICATIONS: Painful varicose veins, left inner thigh.DESCRIPTION OF PROCEDURE: The patient was anesthetized. The left leg was sterilely prepped and draped. An incision was made over the vein, which was dissected up and circled with a 3-0 Vicryl tie. The vein was dissected out through that small incision, and several other incisions were made along the course of the vein to further dissect it out. Five incisions in total were made. The vein was followed as distally as possible and cauterized and divided. It was followed proximally where it went deep, and it was at that point cauterized and divided. The wounds were irrigated, local anesthetic injected, and closed with 3-0 Vicryl subcutaneous suture followed by interrupted 4-0 nylon on the skin. A sterile dressing was applied. The patient was taken to the recovery room in satisfactory condition, having tolerated the procedure well. Sponge, instrument and needle counts were reported as correct.Cohen Andrews, MDElectronically signed by COHEN ANDREWS, MD 1/1/20XX

CaseID: OPD7143 Primary Diagnosis: M87.051 CPT: 27130-RT, 0054T-RT

MEDICAL RECORD OPERATIVE REPORT SEX: Female AGE: 53 Date of Service: 1/1/20XX Service Department: Orthopedic Group Surgery Provider: Dr. Brandon Andrews PREOPERATIVE DIAGNOSIS: Avascular necrosis right hip. POSTOPERATIVE DIAGNOSIS: Avascular necrosis right hip. NAME OF PROCEDURE: Right total hip arthroplasty. Computer-assisted navigation. Fluoroscopy. SURGEON: Brandon Andrews, MD ANESTHESIA: Spinal ANESTHESIOLOGIST: Bob Thompson, MD ESTIMATED BLOOD LOSS: 500 mL COMPLICATIONS: None. DRAINS: ConstaVac reinfusion drain. IMPLANTS: Stryker Accolade II, #2 stem, 54 mm Tritanium chest pin, 36 plus 0 Biolox head. INDICATIONS FOR PROCEDURE: The patient is a female with severe right hip pain due to avascular necrosis confirmed for radiographs and magnetic resonance imaging scan. She is presenting for right total hip arthroplasty having failed conservative treatment. The risks, benefits, alternatives, and potential complications were discussed in detail. Informed consent was obtained. OPERATIVE PROCEDURE: After spinal anesthetic, the patient was carefully positioned on the Hanna table. The left iliac crest, right hip and thigh were prepped and draped in the usual sterile fashion. Intravenous antibiotics were administered and time-out was given. The pins for the navigation were placed in the left iliac crest. The right lateral distal femoral context was dimpled with a 2-mm drill bit for leg length assessment. The right hip was approached through a direct anterior minimally invasive skin incision, creating full-thickness skin flaps. The fascia was incised in the interval with development between the tensor fascia lata and rectus femoris. Retractors were placed superiorly and inferiorly along the femoral neck, and the anterior hip capsule was excised. The third retractor was placed along the anterior over the acetabulum. The femoral

CaseID: OPD7145 Primary Diagnosis: M16.51 CPT: 27130-RT, 0054T

MEDICAL RECORD OPERATIVE REPORT SEX: Male AGE: 58 Date of Service: 1/1/20XX Orthopedic Group Surgery Provider: Dr. Brandon Andrews PREOPERATIVE DIAGNOSIS: Posttraumatic arthritis, right hip. POSTOPERATIVE DIAGNOSIS: Posttraumatic arthritis, right hip. NAME OF PROCEDURE: Right total hip arthroplasty. Computer-assisted navigation includes fluoroscopy. SURGEON: Brandon Andrews, MD ANESTHESIA: Spinal ANESTHESIOLOGIST: Bob Thompson, MD ESTIMATED BLOOD LOSS: 300 mL COMPLICATIONS: 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 obtained. DESCRIPTION OF PROCEDURE: After spinal anesthetic, the patient was positioned on the hana table. The right hip, thigh, and left iliac crest were prepped and draped in the usual sterile fashion. Intravenous antibiotics were administered. A time-out was given. The Stryker navigation pins were placed in the left iliac crest and the right lateral distal femoral cortex was dimpled through a stab incision for leg-length assessment. The right hip was approached through a direct-anterior minimally invasive skin incision, creating full-thickness skin flaps. Retractors were placed superiorly and inferiorly along the femoral neck. The fascia was incised in the interval that was developed between the tensor fascia lata and rectus femoris. Retractors were placed superiorly and inferiorly along the femoral neck and the anterior hip capsule was excised. Inspection revealed marked posttraumatic arthrosis with significant osteoph

CaseID: OPD7119 Primary Diagnosis: O90.0 Secondary Diagnosis: O86.01 CPT: 10180-78, 11042-78

MEDICAL RECORD OPERATIVE REPORTAGE: 38SEX: FEMALEDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: Obstetric wound dehiscencePOSTOPERATIVE DIAGNOSIS: Wound Dehiscence and Infection of obstetric surgical woundPROCEDURES: I & D, Debridement of woundSURGEON: Tyrone Kramer, M.D.FIRST ASSISTANT:ANESTHESIA: GENERAL BY MASK.ESTIMATED BLOOD LOSS: 100 CC OF PUS THAT WAS NOTED OOZING OUT FROM THE INCISION SITE.INDICATIONS: The patient is a 38-year-old Gravida I, Para 1 status post high transverse Cesarean section 2 days ago. The surgery was done by me, (TYRONE KRAMER, MD 12/29/20XX and now the patient has presented with a wound Infection and with very prominent induration at the wound site. The patient's history is significant for myomectomy that was done in 20XX. The patient was consented.PROCEDURE: Informed consent was voluntarily obtained and then the patient was taken to the operating room. In the operating room, the patient was placed in the dorsal lithotomy position. Once anesthesia was found to be adequate, the patient was fully draped in a sterile fashion.A 1 cm incision was found to be open with yellowish pus. 10x10 cm indurated area above the incision noted. An incision was then extended laterally to allow better exposure of induration and pus. At this point, more purulent serosanguinous discharge was noted. 2 cm of fascia was found to be open but there was no evisceration noted. No bowel contents were seen. The wound was fully indurated solid above incision with yellowish fatty necrotic material appreciated. There was an attempt to drain the indurated wound, however, it was not drainable at this time.Necrosis of subcutaneous fat was noted and proper debridement was achieved. The wound opened up at the fascia about 2 cm was repaired without difficulty using 1-0 Vicryl. Copious irrigation was applied. Good hemostasis w

CaseID: OPD7120 Primary Diagnosis: N62 CPT: 19318-50

MEDICAL RECORD 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 the preoperative holding area for reduction mammoplasty. I first started on the patient's right. Tourniquet was placed at the base of the patient's right breast. A 42-mm cookie-cutter was used to outline the areolar margin. Flap was also designed to be a superomedial-based flap. Skin was de-epithelized over the proposed flap. The remaining skin incisions were then made. Dissection was primarily inferior, but a significant amount of the resection was lateral and also towards the anterior axillary line. A small amount of parenchymal tissue was excised superior to the flap to allow transposition of the flap and superior position. Parenchyma superior to this point was elevated off of the chest wall. Hemostasis was achieved with monopolar cautery. A drain was left in place along the lateral aspect. The flap was slightly rotated proximally 30 degrees and transposed superiorly and tacked in place with a

CaseID: OPD6971 Primary Diagnosis: I74.2 CPT: 34101-RT

MEDICAL RECORD OPERATIVE REPORTAGE: 44 Y SEX: FEMALEDATE OF OPERATION: 01/01/20XXPREOPERATIVE DIAGNOSIS: RIGHT UPPER EXTREMITYPROCEDURES: RIGHT UPPER EXTREMITY BRACHIAL AND AXILLARY THROMBECTOMY. POSTOPERATIVE DIAGNOSIS: RIGHT UPPER EXTREMITY THROMBOSIS SURGEON: M.D. ANESTHESIA: GENERAL. ESTIMATED BLOOD LOSS: MINIMAL COMPLICATIONS: NONE. INDICATIONS: A female patient was admitted to the hospital with clinical presentation of acute right upper extremity ischemia. Angiography was done which demonstrated presence of clots in the right axillary artery. At this point, after consultation with the patient and patient's family, a decision was made to proceed with a surgical thrombectomy from the right axillary brachial arteries. PROCEDURE: The patient was brought to the operating room and placed on the OR table in the supine position. General anesthesia was administered. The patient's right upper extremity were prepped and draped for sterile procedure.Incision was done in the proximal right forearm in longitudinal direction above the projection of the brachial artery. The brachial artery was quickly identified and appeared significantly inflamed with the vein tightly adherent to that. A very difficult dissection was followed in this area and finally brachial artery was dissected taking on the Vessel loop as well as radial, ulnar and interosseous arteries.The patient was systemically heparinized with 5000 units of heparin. After 5 minutes of circulation, transverse arteriotomy was made above the trifurcation of the brachial artery within 2 cm above the bifurcation of the brachial artery.We could not find the lumen of the artery, which appeared completely occluded. Finally, we removed something which appeared to be well-organized clot, however, attempt to send the embolectomy cath in proximal and distal direction were unsuccessf

CaseID: OPD7181 Primary Diagnosis: T83.711A Secondary Diagnosis: M60.28 CPT: 57295

MEDICAL RECORD OPERATIVE REPORTAGE: 61SEX: FEMALEDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: SMALL LESS THEN 1 CM. EROSION IN VAGINAPROCEDURES: REMOVAL OF PORTION OF VAGINAL MESH 1CM AND GRANULOMATOUS TISSUE 1CM. BILATERALPOSTOPERATIVE DIAGNOSIS: SMALL VAGINAL EROSION FROM VAGINAL MESH AND GRANULOMA BILATERAL.SURGEON: Trinidad M. Kramer, M.D.FIRST ASSISTANT:ANESTHESIA: GENERAL LARYNGEAL MASK.ANESTHESIOLOGIST: GEORGE JONES, M.D.ESTIMATE BLOOD LOSS: LESS THAN 5 CC.PATHOLOGY: NONE.COMPLICATIONS: NONE.FINDING: 0.5 cm vaginal mesh protruding bilaterally through anterior vaginal wall with granulomaformation around them. A running portion of vaginal mesh and granuloma excised.PROCEDURE: The patient was taken to the operating room where general anesthesia was found to be adequate. The patient was then placed in the dorsal lithotomy position and prepped and draped in the normal sterile fashion.A weighted speculum was then placed into the patient's vagina and the vaginal erosion was noted on the anterior wall of the vagina just below the bladder. A 0.5 cm of vaginal mesh was noted protruding from this lesion and was removed with the Mayo scissors. Two granuloma formations that were around the vaginal mesh erosions were also removed with the Mayo scissors. The wounds were sutured with 2-0 chromic. Good hemostasis was noted. Instruments were removed from patient's vagina.The patient tolerated the procedure well. Sponge, lap and instruments were correct x 2. The patient was taken to the recovery room in a stable condition.Trinidad Kramer, MDElectronically signed by TRINIDAD KRAMER, MD 1/1/20XX

CaseID: OPD7191 Primary Diagnosis: I62.03 CPT: 61154-RT

MEDICAL RECORD OPERATIVE REPORTAGE: 89SEX: FEMALEDATE OF OPERATION: 0/1/20XXPREOPERATIVE DIAGNOSIS: LARGE RIGHT FRONTOPARIETAL CHRONIC SUBDURAL HEMATOMA.PROCEDURES: RIGHT PARIETAL BURR HOLE AND EVACUATION OF CHRONIC SUBDURAL HEMATOMA.POSTOPERATIVE DIAGNOSIS: LARGE RIGHT FRONTOPARIETAL CHRONIC SUBDURAL HEMATOMA.SURGEON: Christopher Kramer, M.D.ANESTHESIA: GENERAL, ENDOTRACHEAL, ASA CLASS IS 3.ESTIMATE BLOOD LOSS: 10 CC.PERIOPERATIVE ANTIBIOTICS: GIVEN.WOUND CLASS: CLEAN.COUNTS: NEEDLE AND SPONGE COUNTS WERE CORRECT.SPECIMEN: NONE.DRAINS: JP.COMPLICATIONS: NONE.DISPOSITION: ON COMPLETION OF THE CASE, THE PATIENT HAD REMOVAL OF THE LARYNGEAL MASK AIRWAY. FOLLOWING THIS SHE WAS OPENING HER EYES, FOLLOWING COMMANDS AND MOVING ALL FOUR EXTREMITIES AT BASELINE.INDICATIONS: The patient is a female who recently moved from Puerto Rico to the Bronx with her family. The family was concerned about recent memory loss. The noncontrast head CT revealed a large right-sided chronic subdural hematoma with mass effect upon the right frontal and parietal lobes. The maximum width of subdural hematoma was approximately 2 cm. She was referred to the emergency department. On neurological exam, she was awake, alert and was able to follow commands in Spanish. She has a slight pronator drift in the left upper extremity. We discussed the options of surgery to evacuate the hematoma as well as observation. We discussed all the risks, benefits and alternatives. The risks included but were not limited to infection, hemorrhage, CSF leak, meningitis, new neurological deficits including paralysis and even death. The benefits included removal of subdural hematoma and decreased mass effect on the underlying brain. No guarantee of results was made. The patient's daughter wished to proceed with surgery and she signed written consent. The patient herself also

CaseID: OPD7316 Primary Diagnosis: C43.71 CPT: 14020, 27632-RT

MEDICAL RECORD OPERATIVE REPORTSEX: FEMALEAGE: 43DATE: 01/01/20XXPREOPERATIVE DIAGNOSIS: Incomplete excision of melanoma, right calf.POSTOPERATIVE DIAGNOSIS: Incomplete excision of melanoma, right calf.OPERATION:1. Tumor excision, right calf .2. Rhomboid rotation flap, right calf .Surgeon: Christopher Thomas, M.D.1st Assistant: Jonathan Jones, M.D.Anesthesia:OPERATIVE INDICATIONS: Ms. Smith had an incompletely excised melanoma on her right calf. We have not reviewed the pathology. The margins were grossly positive. It was reportedly 0.4 mm and a Clark level II. This is yet to be confirmed. I do not know the ulceration status. She obtained a PET scan on X/X/20XX, which was clear. She has no adenopathy. Chest x-ray was clear December 15, 20XX. She presents today for a resection and closure. We are debating as to whether to do a flap or a skin graft.OPERATIVE PROCEDURE: The patient was taken to the general operating room where after induction placed under general endotracheal anesthesia. Preoperative parenteral antibiotics were administered. She was placed supine on the operating room table, had the right lower extremity including the abdomen and groin prepped and draped sterilely, widely, and freely in the usual fashion. We addressed the right calf where there was a simple dermatologic scar. We made our incision no closer than 1.5 cm away from the surrounding erythema of the scar. This created a diameter of excision approximately 6 cm. We opted to remove a circular defect.The incision was taken down through skin and subcutaneous tissue and meticulous hemostasis achieved with electrocautery. It appeared that she had a dual saphenous vein system. Smaller branches of the saphenous vein were tied and ligated as we went through the skin incision. We came down upon the fascia, cut the fascia, and then removed the skin, subcuta

CaseID: OPD7365 Primary Diagnosis: N83.201 Secondary Diagnosis: N73.6 CPT: 58925

MEDICAL RECORD OPERATIVE REPORTSEX: FEMALEAGE: 47DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS: A 47-YEAR-OLD GRAVIDA III PARA 1-0-2-1 WITH RIGHT OVARIAN CYST.PROCEDURES: LAPAROSCOPY, OBLIQUE LAPAROTOMY.POSTOPERATIVE DIAGNOSIS: A 47-YEAR-OLD GRAVIDA III PARA 1-0-2-1 WITH RIGHT OVARIAN CYST.SURGEON: Dominick M. Kramer, M.D.FIRST ASSISTANT:ANESTHESIA: GENERAL ESTIMATED BLOOD LOSS: 60 CC.IV FLUIDS: 1300 CC OF LACTATED RINGER HAS BEEN TRANSFUSED DURING THE PROCEDURE.URINE OUTPUT: 150 CC OF URINE HAS BEEN PRODUCED DURING THE PROCEDURE.PROCEDURE: The patient was taken to the operating room where general anesthesia was obtained without difficulty. The patient was then examined under anesthesia and no mass found in the pelvis. She was then placed in the dorsal lithotomy position and draped in the normal sterile fashion.A sponge holding forceps has been introduced through the vagina. The patient catheterized. Attention was then turned to the patient's abdomen where an infraumbilical curved incision has been made for laparoscopy. As there was adhesion we did not enter the abdomen through infraumbilical incision .A mini laparotomy was performed, A transverse incision was made 2 cm above the symphysis pubis and superficial fossa anterior layer of rectus sheath was dissected. The rectus muscle was densely adherent to the rectus fascia. Malard technique was performed. There were dense bowel adhesions.The peritoneum was opened with difficulty. There were adhesions between large bowel , omentum and adnexa. Right-sided adnexa was not present, left-sided adnexa was distorted to the right side of the pelvis by adhesions. There was a small 2 x 2 cm right ovarian cyst that was benign. There was no adnexal mass detected after proper hemostasis. The rectus fascia was closed with #1 looped PDS. Proper hemostasis was taken in the superfic

CaseID: OPD7121 Primary Diagnosis: R92.0 CPT: 19125-LT

MEDICAL RECORD OPERATIVE REPORTSEX: Female AGE: 61DATE OF OPERATION: 01/01/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Left breast microcalcifications.POSTOPERATIVE DIAGNOSIS: Left breast microcalcifications.PROCEDURE PERFORMED: Wire-localized excisional biopsy of left breast microcalcifications.ANESTHESIA: General.PREOPERATIVE MEDICATIONS: Ancef.INDICATIONS: This is a very nice female who has been found to have an increased number of left superior breast microcalcifications, she had wire localization by another provider. Her breast compressed too thinly for stereotactic biopsy, and therefore, she was advised to undergo wire-localized excision. We discussed the risks and benefits of surgery, and she is ready to proceed.FINDINGS: The calcifications of interest are all located within the specimen. This is in the central superior left breast.DESCRIPTION OF PROCEDURE: The patient underwent wire localization which occurred uneventfully. The wire enters the breast from a superior to inferior aspect. The cluster of interest was noted to be somewhat central and superior. She was anesthetized in a supine position and then I examined her breast carefully and trimmed the wire externally. She was prepped with the Betadine solution and draped in the sterile fashion. Time-out was confirmed. I created a curvilinear incision in the superior aspect of her left nipple areolar border. Skin flaps were raised and the wire was identified and the area of interest was dissected surrounding this. There was a layer of breast tissue between the biopsy cavity and the pectoralis muscle, but this was in a relatively thin portion of her generally thin breast. A short stitch was placed in the superior margin and a long stitch was placed in the lateral margin. The specimen was sent to Radiology where they confirmed all of the calcifications

CaseID: OPD7124 Primary Diagnosis: L72.3 CPT: 10060

MEDICAL RECORD OPERATIVE REPORTSEX: Female AGE: 65DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Infected sebaceous cyst, right back.POSTOPERATIVE DIAGNOSIS: Same.PROCEDURE PERFORMED: Incision and drainage of infected sebaceous cyst, right back.ANESTHESIA: Local.SKIN PREP: Betadine.DRAINS: None (packed open).DESCRIPTION OF PROCEDURE: The area was prepped and draped. One percent Xylocaine was administered and a cruciate incision was made into the abscess cavity. Culture was taken. The wound was irrigated and debris was removed. It was packed with lodophor gauze and covered with a dry dressing. The patient tolerated the procedure well. She will follow up in the office.Cohen Andrews, MDElectronically signed by COHEN ANDREWS, MD 1/1/20XX

CaseID: OPD7152 Primary Diagnosis: I12.0 Secondary Diagnosis: N18.6, T82.590A, Z99.2 CPT: 36818, 37607

MEDICAL RECORD OPERATIVE REPORTSEX: Female AGE: 67DATE 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 administered and an incision was made over the brachial artery which was also dissected out and encircled with a vessel loop. The patient was given 5000 units of heparin intravenously. After three minutes, the distal cephalic vein was ligated with 3-0 Vicryl and was divided. It was pulled up through the tunnel from the antecubital incision up to the upper arm incision. It was then tunneled over to the brachial artery dissection. The brachial artery was occluded with noncrushing DeBakey clamps and was opened longitudinally. The vein was trimmed and spatulated and sutured to the artery with 6-0 Gore-Tex suture. The fistula was flushed by opening the distal artery which then reclamped while the proximal artery was opened to flush the fistula. The distal clamp was then again released. An excellent thrill was present. The vein dilated up nicely.Hemostasis was achieved with Gelfoam soaked in topical thrombin. The previous graft was then ligated

CaseID: OPD7174 Primary Diagnosis: K80.10 CPT: 47563, 74300-26

MEDICAL RECORD OPERATIVE REPORTSEX: Female AGE: 69DATE OF OPERATION: 01/1/20XXSURGEON: Dr. Cohen Andrews PREOPERATIVE 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 PROCEDURE: The abdomen was prepped and draped. A small right subcostal incision was made through which a nonbladed 5-mm Optiview port was placed under direct vision. The abdomen was insufflated and the scope was inserted. The abdominal contents were briefly inspected. I was able to place a 5-mm port above the umbilicus, avoiding all of the lower abdominal adhesions. The scope was then placed into that port, while the patient was placed in reverse Trendelenburg position. Additional ports were placed in the epigastrium and right upper quadrant.Adhesions to the liver were taken down sharply with scissor dissection. The gallbladder was grasped and elevated. The infundibulum was retracted laterally while the cystic artery and cystic duct were dissected out. The cystic artery was not readily identifiable. A hemoclip was placed over what I thought might be the cystic artery coursing up the ga

CaseID: OPD7123 Primary Diagnosis: N63.24 CPT: 19120-LT

MEDICAL RECORD OPERATIVE REPORTSEX: Female AGE: 70DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Left breast mass.POSTOPERATIVE DIAGNOSIS: Left breast mass, pathology pending.PROCEDURE PERFORMED: Left breast (excision of mass)biopsyANESTHESIA: Local MAC.SKIN PREP: ChloraPrep.DRAINS: None.INDICATIONS: Palpable mass, 6 o'clock left breast lower inner quadrantINDINGS: A mass was actually difficult to appreciate within the breast tissue.DESCRIPTION OF PROCEDURE: The left breast was prepped and draped. One percent Xylocaine was administered and an inferior periareolar incision was made and carried down to the area of the palpable mass. The area was grasped with an Allis clamp and excised using sharp dissection and electrocautery for hemostasis. There was really no palpable mass within the specimen and no other palpable masses in the area. Specimen was submitted for pathologic evaluation. Hemostasis was achieved. The wound was irrigated and closed with 3-0 Vicryl subcutaneous suture followed by a running subcuticular 4-0 Vicryl skin closure. Sterile dressing was applied. The patient was taken to the recovery room in satisfactory condition having tolerated the procedure well. Sponge, instrument and needle counts were reported as correct.Cohen Andrews, MDElectronically signed by COHEN ANDREWS, MD 1/1/20XX

CaseID: OPD7130 Primary Diagnosis: D05.12 CPT: 19301-LT, 38525-LT, 38900-LT

MEDICAL RECORD OPERATIVE REPORTSEX: Female AGE: 71DATE 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 partial mastectomy.FINDINGS:1. Sentinel lymph node negative for metastatic disease on examination by the pathologist while the patient was under anesthesia.2. Clip within the original excised specimen by radiologist reported into the operating roomDESCRIPTION OF PROCEDURE: A signed informed consent was on the chart at the time of the procedure. The patient was brought to the operating room and placed in supine position. General anesthesia with LMA was induced. The patient was administered 1 g of Ancef IV preoperatively. 2 cc of methylene blue mixed with 8 cc of normal saline was infused into the Subareolar space in a sterile fashion. The breast was massaged for 5 minutes and then the left breast, axilla, and left arm and shoulder were prepped and draped in a sterile fashion. Using the navigator device, the sentinel lymph node activity was localized in the anterior left axilla after first infusing the skin and soft tissue with local ane

CaseID: OPD7156 Primary Diagnosis: J94.8 Secondary Diagnosis: J98.4, Z86.74 CPT: 32551-RT

MEDICAL RECORD OPERATIVE REPORTSEX: Female AGE: 81DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Right pneumothorax.POSTOPERATIVE DIAGNOSIS: Right hydropneumothorax with adhesions and loculations.PROCEDURE PERFORMED: Right closed-tube thoracostomy.ANESTHESIA: Local.SKIN PREP: ChloraPrep.DRAINS: 28-French Argyle chest tube.INDICATIONS: The patient had cardiac arrest with cardiopulmonary resuscitation and was noted on chest x-ray today to have a probable right pneumothorax. CT scan of the chest confirms 40%to 50% right pneumothorax.FINDINGS: Right hydropneumothorax with loculation and adhesions.DESCRIPTION OF PROCEDURE: The right chest was prepped and draped. 1% Xylocaine was administered and an incision was made over the fifth intercostal space midaxillary line. A Kellyclamp was inserted through the fifth intercostal space. I then inserted a finger to palpate and found that there were adhesions. I dissected bluntly anteriorly and entered an open area with pneumothorax. The chest tube was inserted into that area and directed anteriorly. Serous fluid spilled on the bedding, at least 100 mL. The chest tube was initially clamped while the 0 silk suture was placed and the chest tube was tied to the skin with suture. The chest tube was then hooked up to the Pleur-evac on 20 cm suction. A sterile dressing was applied. A follow-up chest x-ray is ordered. The patient tolerated the procedure well.Cohen Andrews, MDElectronically signed by COHEN ANDREWS, MD 1/1/20XX

CaseID: OPD7192 Primary Diagnosis: H65.31 CPT: 69436-RT

MEDICAL RECORD OPERATIVE REPORTSEX: MAGE: 4DOS; 1/1/20XXPHYSICIAN: 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 operating room and placed on the operating table in a supine position. The patient was induced with general anesthesia by mask. After satisfactory induction of anesthesia, the right ear was operated on using an operating microscope. The cerumen was removed from the external canals. Ears were irrigated with saline and carefully suctioned. Tympanic membranes were carefully inspected. An anterior-inferior myringotomy incision was made. The middle ear was aspirated. Donaldson tympanostomy tube was inserted. Floxin Otic was inserted into the external canals. The patient tolerated the procedure well without complications encountered. The patient recovered from general anesthesia and was transported to the recovery room in stable and satisfactory condition.J. Kramer, MDElectronically signed by J. KRAMER, MD 1/1/20XX

CaseID: OPD6958 Primary Diagnosis: S42.022A CPT: 23515-LT

MEDICAL RECORD OPERATIVE REPORTSEX: MALE AGE: 35DATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: LEFT MIDSHAFT CLAVICLE FRACTURE DISPLACED.PROCEDURES: LEFT CLAVICLE ORIF WITH FLUOROSCOPY.POSTOPERATIVE DIAGNOSIS: LEFT MIDSHAFT CLAVICLE FRACTURE DISPLACED.FLUOROSCOPY (Included in Procedure)SURGEON: Dr. MDANESTHESIA: GENERAL, ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 100 CC.ANTIBIOTICS: CLINDAMYCIN 900 MG.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who had a motorcycle accident with the left clavicle fractured which was widely displaced with the proximal fragment appearing to be impaled into the trapezius. Options, risks and benefits were discussed with the patient. He agreed with the open reduction internal fixation.PROCEDURE: The patient was brought to the operating room and anesthesia was induced via endotracheal tube. The left upper extremity and chest were then prepped and draped in sterile fashion. An incision was marked over the fractured clavicle and infiltrated with lidocaine 1% with epinephrine. It was then established, taken down through the subcutaneous tissue to the pectoral trapezial fascia which was incised longitudinally along the clavicle and the inferior surface of the clavicle was dissected to protect the lung.The fracture fragments were subperiosteally dissected, irrigated out and curetted. Anatomic reduction was then performed and held with K-wire. An Acumed clavicle plate was then placed along the superior surface of the clavicle. A 2.8 drill was used to create drill holes and the fracture was compressed followed by locking screws. C-arm images confirmed anatomic reduction and good position of the hardware. The shoulder was put through a full range of motion.The wound was then irrigated out. Trapezial pectoral fascia was closed with running and interrupted 2-0 Vicryl. The subcutaneous tissu

CaseID: OPD7358 Primary Diagnosis: C49.22 CPT: 27324-LT

MEDICAL RECORD OPERATIVE REPORTSEX: MALE AGE: 54DOS: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Hematoma versus sarcoma. POSTOPERATIVE DIAGNOSIS: Sarcoma PROCEDURE PERFORMED: Open biopsy. ANESTHESIA: General. INDICATIONS: 54-year-old gentleman with a large mass that has arisen fairly suddenly in the proximal anterolateral thigh. He was sent over by his primary care provider with the feeling that this was probably a large lipoma. I was concerned about its characteristics on physical exam and it's relatively sudden appearance. I obtained an MRI. Final impression was a 9.5 x 8.5 x 14.2 cm intramuscular sarcoma involving the proximal portion of the tensor fascia lata muscle. I obtained a staging CT of his chest, which was normal. I attempted a Tru-Cut needle biopsy of this mass. As I entered the tumor mass, there was a moderate amount of brownish liquid that emanated from the Tru-Cut puncture site, which I felt to be consistent with old blood. Multiple passes of the needle were done. I didn't' really obtain too much tissue, but did send what I got for examination. In addition, I was able to obtain about 3 cc of fluid within the mass itself and sent this for cytological exam. The Tru-Cut biopsies revealed benign fibrous tissue. No tumor. The cytology was negative for tumor cells and revealed old blood and macrophages, consistent with remote hemorrhage. At this point, this either represents a hematoma from some unknown trauma or my concern is that this represents a hemorrhage into a tumor. At this point, I see no alternative but to do an open exploration and biopsy. My plan is to open this up, hopefully not to destroy any tissue plains for any subsequent surgery, but needing to get into the mass itself, hopefully drain it, and this will be a hematoma or otherwise make sure to get tissue. DESCRIPTION OF PROCEDU

CaseID: OPD7396 Primary Diagnosis: H33.012, E11.3542 CPT: 67113-LT

MEDICAL RECORD OPERATIVE REPORTSEX: MALEAGE: 31DOS: 1/1/20XXPHYSICIAN: Shaun Kramer, MDPREOPERATIVE DIAGNOSIS: Rhegmatogenous retinal, left eye. POSTOPERATIVE DIAGNOSIS: Rhegmatogenous retinal, left eye. OPERATIVE PROCEDURE: Trans pars plana vitrectomy, fluid/gas exchange, and a laser photocoagulation, left eye.SURGEON: Shaun Kramer, MDANESTHESIA: Local with MACINDICATIONS: The patient is a 31-year-old male with a history proliferative diabetic(type II) retinopathy, who has previously undergone vitrectomy and panretinal photocoagulation. The patient presented with complaints of temporary loss of vision. On examination, the patient was noted to have a retinal detachment with a single break. The patient presents now for surgical treatment of above. PROCEDURE IN DETAIL: The patient was brought to the operating room in stable condition, placed on the operating room table in the supine position. Under monitored conditions and mild IV sedation, the patient was given a retrobulbar block on the left side with approximately 5 mL of a 1:1 mixture of 4% lidocaine and 0.75% Marcaine with Amphadase added. The patient was then prepped and draped in the usual sterile fashion. A lid speculum was placed to maintain the lids in open fashion on the left side. Calibers were set at 4 mm to demarcate the sites for cannula placement. A 25-gauge cannula on a trocar was introduced infratemporally following displacement of the conjunctiva. The trocar was removed and the infusion line inserted into the cannula and fashioned in position. Forceps were then used to grasp the hub of the cannula and rotate the tip through the pupil to ensure it was free of any overlying tissue. The infusion was then turned on.The 25-gauge cannulae on trocars were then introduced supranasally and supratemporally following displacement of the conjunctiva. The trocars w

CaseID: OPD7126 Primary Diagnosis: L72.3 CPT: 12051, 11441

MEDICAL RECORD OPERATIVE REPORTSEX: Male AGE: 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

CaseID: OPD7195 Primary Diagnosis: C73 Secondary Diagnosis: C77.0 CPT: 60252-78

MEDICAL RECORD OPERATIVE REPORTSEX: MaleAGE: 46DATE OF OPERATION: 1/1/20XXSURGEON: Dr. Cohen AndrewsPREOPERATIVE DIAGNOSIS: Papillary carcinoma of the thyroid with lymphatic metastases.POSTOPERATIVE DIAGNOSIS: Papillary carcinoma of the thyroid with lymphatic metastases.PROCEDURE PERFORMED: Total thyroidectomy and limited central compartment lymph node dissection.ANESTHESIA: General.SKIN PREP: ChloraPrep.DRAINS: None.INDICATIONS: This patient underwent parathyroidectomy for tertiary hyperparathyroidism with parathyroid hyperplasia yesterday by me. A lymph node biopsied in the central compartment inferior to the thyroid gland revealed metastatic papillary carcinoma. The patient was returned to the operating room for total thyroidectomy.FINDINGS: The thyroid was moderately heterogeneous and dense, but no palpable separate nodules. No other obvious adenopathy was found.DESCRIPTION OF PROCEDURE: The neck was prepped and draped. The low collar incision was reopened, dividing the strap muscles in the midline, separating them. The left lobe of the thyroid was further mobilized. There was quite a bit of early inflammatory change after the most recent operation and bleeding was more than usual. The upper pole was dissected out and the upper pole vessels were clamped, divided and ligated with 2-0 silk. The recurrent laryngeal nerve was identified. The middle thyroid vessels, or what was left of them, were hemoclipped and divided. The ligament of Berry was divided and the thyroid was dissected up off of the trachea. The inferior pole was also dissected up. The isthmus was divided with the cautery and the wound was irrigated and Gelfoam soaked in thrombin was applied for hemostasis. Meanwhile, the inferior central compartment was dissected up, taking care to avoid injury to the recurrent laryngeal nerve. Adipose tissue and contain

CaseID: OPD7028 Primary Diagnosis: Z48.812 Secondary Diagnosis: I51.7, R91.8, J98.11, Z95.2 CPT: 71045-26

MEDICAL RECORD RADIOLOGY REPORTMountain HospitalNAME: Smith, LeandraSEX: FAGE: 75DATE OF EXAM: 1/1/20XXREFERRING PHYSICIAN(S): Jacob Kramer M.D.PROCEDURE: X-RAY CHEST, ONE VIEWCOMPARISON: 0X/13/20XXINDICATIONS: Post valve replacement.TECHNIQUE: A single AP portable view of the chest was performed.FINDINGS: The right internal jugular Swan-Ganz catheter and sheath have been removed. The left subclavian central venous catheter and chest tubes remain in place. There are changes of previous sternotomy. The heart is mildly enlarged. Left lung base opacity is again seen and unchanged. No pneumothorax is seen.CONCLUSION:1. INTERVAL REMOVAL OF THE RIGHT INTERNAL JUGULAR SWAN-GANZ CATHETER AND SHEATH. OTHER SUPPORT LINES AND TUBES ARE UNCHANGED.2. CARDIOMEGALY AND CHANGES OF PREVIOUS STERNOTOMY.3. UNCHANGED LEFT LUNG BASE OPACITY OBSCURING THE LEFT DIAPHRAGM, ATELECTASIS.Electronically signed by Technician 1//20XX

CaseID: OPD7149 Primary Diagnosis: R91.1 Secondary Diagnosis: Z85.118, Z90.2, Z92.3, Z92.21 CPT: 31622

MEDICAL RECORD OPERATIVE REPORTSex: FAGE: 54DOS: 1/1/20XXSURGEON: Frederic KramerANESTHESIOLOGIST:ANESTHESIA: General endotracheal anesthesia.PREOPERATIVE DIAGNOSIS: Right upper lobe nodule suspicious for cancer.POSTOPERATIVE DIAGNOSIS: Right upper lobe nodule suspicious for cancer.TITLE OF OPERATION: Fiberoptic bronchoscopy and discontinuance of planned pulmonary resection.INDICATIONS: This patient had undergone a left upper lobectomy following high dose radiation and concurrent chemotherapy for a Pancoast tumor. She subsequently on follow up has presented with a small nodule in the apex of the right lung which is enlarging and is suspicious for a metachronous primary lung cancer. She was being anesthetized with the intent of performing a right apical anatomic segmentectomy.PROCEDURE: Under satisfactory general anesthesia, an Olympic fiberoptic bronchoscope was advanced down the endotracheal tube. The right-sided anatomy was perfectly normal and all of the segments were seen. On the left side, the mucosa was normal, although there appeared to be some extrinsic mucosal compression at the takeoff of the left lower lobe bronchus. The left upper lobe stump was normal. The bronchoscope was removed. Anesthesia then had significant difficulty placing a double lumen endotracheal tube. Three different tubes were inserted in sequence and during these insertions there was some bleeding on the left side and despite irrigation some blood remained in the left lower lobe bronchus. We participated in examining this airway and made a decision to terminate the procedure since the patient would be ventilated in a single lobe which would be dependent and there would be an additional risk of Acute Respiratory Distress Syndrome.We elected to wake this patient and reschedule the procedure for one week's time.Frederic Kramer, MDElectronicall

CaseID: OPD7102 Primary Diagnosis: I42.1 E/M Level: 99214

MEDICAL RECORD PROGRESS NOTE - ESTABLISHED PTAGE: 67Consulting Physician:Referring Physician:Date: 01/01/20XXREASON FOR VISIT1. 67-yo with cardiac murmur for evaluation.2. Incidental asymptomatic hypercalcemia.ALLERGIES: Penicillin and sulfa.MEDICATIONSAlendronate 70 mg weeklyMultivitaminsVitamin D 2000 IU q.d.Vitamin C 500 mg q.d.Biotin 500 mg q.d.Claritin OTC 2-3 times weeklyExcedrin 2 tabs b.i.d.Metoprolol succinate 25 mg q.d.She is not aware of exertional shortness of breath. She has had no chest discomfort. No exertional lightheadedness or syncope. She is also to commence eye drops for early right ocular glaucoma.INTERVAL HISTORY: Recent workup showed quite marked asymptomatic septal hypertrophy with inducible left ventricular outflow tract obstruction with amyl nitrate (to a maximum of only 22 mmHg). Additionally, she was found to have an evident bicuspid aortic valve with moderate aortic insufficiency.She underwent a stress echocardiogram to evaluate for ischemia on (12/15/20XX) notable for:1. Quite marked increase in systolic anterior motion of the anterior mitral leaflet.2. Blood pressure response was flat.3. Exercise capacity was Functional class III limited by shortness of breath.4. There was no exercise-induced hypoxemia.Lipid panel (12/15/20XX) shows:1. Total cholesterol 268, LDL directly measured 143, HDL 107, triglycerides 123.2. The rest of the labs are unremarkable.3. TSH 2.6.EKG (12/15/20XX) shows:1. Possible left atrial abnormality.2. QTc is normal at 402 ms.PHYSICAL EXAMINATIONVITAL SIGNS: Weight 102 lbs. BP 122/64 in the left arm. Pulse 69 and regular, oxygen saturation 92% on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Good air entr

CaseID: OPD7104 Primary Diagnosis: I27.22, I48.20, G47.30 Secondary Diagnosis: Z95.5, Z99.89, Z99.81, Z79.01, Z79.82 CPT: 93351 E/M Level: 99214-25

MEDICAL RECORD PROGRESS NOTESex: FAge: 74Attending Physician:Referring Physician:Date: 01/01/20XXPROBLEM LIST1. 74 year old with history of marked left ventricular diastolic dysfunction, secondary to pulmonary hypertension.2. Four years S/P coronary artery stent.3. Chronic atrial fibrillation with history of uncontrolled rate intermittently.4. Severe sleep apnea; on CPAP and oxygen as Rx' d.5. Type 2 diabetes, difficult to control.6. Questionable history of COPD.ALLERGIES: Atenolol (fatigue)MEDICATIONSVerapamil SR 240 mg a.m., 120 mg p.m.Lisinopril 40 mg q.d.Metformin 100 mg b.i.d.Glyburide 5 mg 1 b.i.d.Coumadin ADLovastatin 20 mg q.d.Docusate q.d.Alpha-lipoic acid q.d.Multivitamin q.d.Vitamin C 1000 mg q.d.Calcium, magnesium, and zincMetamucil 12 gm q p.m.Aspirin 81 mg q.d.Digoxin 0.125 mg q.d.Chlorthalidone 25 mg q.d.Lactulose p.r.n.Gabapentin 300 mg 3 caps q.d.Tamsulosin 0.4 mg q. p.m.Iron 130 mg q.d.Avodart 0.5 mg q. p.m.INTERVAL HISTORY: The patient continues with exertional shortness of breath which has developed over the last three months.Echocardiogram (01/01/20XX) shows:1. Progressive increase in his pulmonary artery hypertension to the high-70s.Pulmonary function tests (01/01/20XX) show:1. Mild airways obstruction only.2. Diffuse capacity was normal.3. Lung volumes were normal.He has been on his CPAP plus oxygen for 2-3 years. He questions the accuracy of the diagnosis.Labs (01/01/20XX) show:1. Slightly elevated TSH at 5.17. He was initiated on Synthroid 25 mcg q.d. Follow-up TSH is pending.2. Fasting glucose of 148.3. Hemoglobin 11.2 grams percent with macrocytic indices, otherwise normal CBC.Stress echocardiogram performed in the outpatient facility today shows:Supervising Physician: Robert Jones, MD1. Study was limited to 1 minute into stage II of a standard Bruce protocol by fatigue.2. No evidence of isch

CaseID: OPD7089 Primary Diagnosis: R60.0, Z95.2, Z79.01 E/M Level: 99024

MEDICAL RECORD 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 and regular, oxygen saturation 93% on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest has normal contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 and normal. No murmur, clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial dorsalis pedis pulses intact. Leg swelling resolving.GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.SKIN: Chest: Midline wound has now healed appropriately. Skin is otherwise pink, warm, dry and intact No rashes.NEUIROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal.ASSESSMENT1. localized edema legs, resolving2.

CaseID: OPD7038 Primary Diagnosis: R05.9 CPT: 71046-26

MEDICAL RECORD RADIOLOGY REPORT LOCATION: AAPC HospitalSEX: FemaleAGE: 52DOS: 1/1/20XXPHYSICIAN(S): M.D.PROCEDURE: X-RAY CHEST TWO VIEWS, PA AND LATERALCOMPARISON: None.INDICATIONS: Cough.TECHNIQUE: PA and lateral radiographs of the chest were performed.FINDINGS: The heart and other mediastinal structures are normal. The lungs are well expanded with no evidence of active disease. The hemidiaphragms and bony structures are normal.CONCLUSION: NORMAL TWO VIEW CHEST.Electronically signed by 1/1/20XX

CaseID: OPD7032 Primary Diagnosis: S06.5X9A CPT: 70450

MEDICAL RECORD RADIOLOGY REPORTLocation: 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.Electronically signed by 1/1/20XX

CaseID: OPD7024 Primary Diagnosis: G93.2 CPT: 63741

MEDICAL RECORD SEX: FEMALEAGE: 20DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS: PSEUDOTUMOR CEREBRI.PROCEDURES: PLACEMENT OF A LUMBOPERITONEAL SHUNT.POSTOPERATIVE DIAGNOSIS: PSEUDOTUMOR CEREBRI.SURGEON:ANESTHESIA: GENERAL.ESTIMATE BLOOD LOSS: APPROXIMATELY 25 CC.DISPOSITION: THE PATIENT WAS TRANSFERRED TO THE RECOVERY ROOM IN STABLE CONDITION FURTHER MONITORING.COMPLICATIONS: NONE.INDICATIONS: The patient is a female with a history of recently developed pseudotumor cerebri, profound visual loss and headache. The patient was managed with spinal tap and with Diamox without success. We were consulted for placement of a draining device. Our recommendation was to proceed with a lumboperitoneal shunt. This was explained to the patient and to her family to their understanding. Surgical and nonsurgical options were discussed including the possibility of a VP shunt. The risks and benefits were discussed and their questions were answered to their satisfaction.PROCEDURE: The patient was brought into the operating room and transferred to the operating table. General anesthesia was induced and she was endotracheally intubated. She was then placed in the lateral decubitus position with the right side up and her knees bent sharply towards her chest. The surgical site was then prepped and draped in usual fashion.With a scalpel, a minuscule midline incision was made in the middle of the back approximately at the level of L3-4 between two spinous processes. Through this incision, a Tuohy needle was introduced between spinous processes into the thecal sac. Once the trocar was removed, clear colorless CSF was obtained. Through the Tuohy needle, the lumbar part of the LP shunt was introduced to a depth of approximately 30 to 35 cm. The Tuohy needle was withdrawn and the catheter was left in place.The catheter was then tunneled from th

CaseID: OPD6930 Primary Diagnosis: S52.252C, S52.352C CPT: 25575-LT

MEDICAL RECORD SEX: MALE Age: 27DATE OF OPERATION: 01/1/20XXPREOPERATIVE DIAGNOSIS: LEFT BOTH BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED DUE TO GUNSHOT WOUND ULNA AND RADIUS SHAFTS TYPE IIIPROCEDURES: LEFT FOREARM INTRAMEDULLARY NAILING WITH ACUMED INTRAMEDULLARY NAILS, REPEAT IRRIGATION OF GUNSHOT WOUNDSPOSTOPERATIVE DIAGNOSIS: LEFT BOTH BONE FOREARM OPEN FRACTURE DISPLACED COMMINUTED DUE TO GUNSHOT WOUND ULNA AND RADIUS SHAFTS TYPE IIISURGEON: Stephanie Andrews MDANESTHESIA: GENERAL, ENDOTRACHEAL TUBE.ESTIMATE BLOOD LOSS: 10 CC.TOURNIQUET TIME: 60 MINUTES.ANTIBIOTICS: ANCEF 1 GM.COMPLICATIONS: NONE.INDICATIONS: The patient is a male who sustained gunshot wounds to the abdomen and the left forearm and he was stabilized by general surgery (ulna and radius shaft fractured) Options, risks and benefits were discussed with the patient and his father and they agreed with the internal fixation. I recommend an intramedullary rod due to the comminution and the probability of poor fixation with plating on the radius.PROCEDURE: The patient was brought to the operating room and anesthesia was induced via endotracheal tube. The left upper extremity was prepped and draped in sterile fashion. It was elevated, and the tourniquet was inflated to 250.A longitudinal incision was made over the tip of the olecranon and taken down to the triceps which was split longitudinally over the tip of the olecranon. The medullary canal was opened with the awl and a reamer was placed on the medullary canal across the fracture site. The length was measured and Acumed ulnar nail was then placed and the proximal interlock was placed from the radial to medial direction using the guide and stab incision. This obtained good purchase.Attention was then turned to the radius and under C-arm control an incision was made over the distal radius over the fou

CaseID: OPD7164 Primary Diagnosis: J35.03 CPT: 42820

MEDICAL RECORD SEX: MALEAGE: 9DOS: 1/1/20XXPREOPERATIVE DIAGNOSIS: Chronic adenoiditis and Tonsillitis.POSTOPERATIVE DIAGNOSIS: Chronic adenoiditis and Tonsillitis.OPERATIVE PROCEDURE: Tonsillectomy and adenoidectomy.SURGEON: J. Kramer, MDANESTHESIA: General endotracheal.ESTIMATED BLOOD LOSS: Less than 20 mL.COMPLICATIONS: None.POSTOP CONDITION: Good.OPERATIVE FINDINGS: Tonsils were symmetrically enlarged, somewhat embedded and cryptic. Adenoids were moderately enlarged.INDICATIONS FOR SURGERY: This is a male who has had a history of frequent episodes of tonsillitis. He has no personal or family history of bleeding disorder.OPERATIVE PROCEDURE: The patient was taken to the operating room and placed on the table in a supine position. The patient was induced for general oral endotracheal anesthesia. After satisfactory induction of anesthesia, the neck was extended with a roll. Head drape was placed. A ring mouth gag was inserted. A red rubber catheter was passed through the right nostril to retract soft palate. The nasopharynx was examined with mirror, and adenoids were removed with adenoid curettes along the fossa of Rosenmuller and then in midline. Sponges were placed in the nasopharynx for hemostasis.First left and then right tonsil was removed in the following fashion: The tonsil was grasped with a tonsil Allis. The peritonsillar space was injected with 0.25% plain Marcaine. The mucosa of the posterior and then anterior tonsillar pillar was incised with a 12-scalpel blade. Bipolar Metzenbaum scissors were used to dissect a plane between the tonsillar capsule and the underlying superior constrictor muscle. The bipolar cautery scissors were used to dissect the tonsils away from the superior constrictor muscle from the superior down to the inferior pole. Bipolar cautery was used to coagulate the vessels as they were enc

CaseID: OPD7470 Primary Diagnosis: Z47.89 E/M Level: 99455

RECORD ">MEDICAL RECORD WORKER'S COMPENSATIONORTHOPAEDIC FOLLOWUP REPORTSEX: MALEAGE: 38DOS: 1/1/20XXInsurance: workers compMD: Dr. Brandon AndrewsUS Department of LaborLondon, KY 40742RE: Joss SmithEMPLOYER: ABC Co.Dear Claims Examiner:Mr. Smith follows up for his right hip following arthroscopic surgery, 6 months ago. He is doing very well since his flare up that he had at his last visit. He is working out. He is riding a bike and doing elliptical. He still has not tried jogging yet. He reports some discomfort when he plants and rotates to the opposite side of his hip. He has no more pain at all when he goes up and down stairs which he had prior to surgery. He has no more popping or catching of the hip.PHYSICAL EXAMINATION:On examination, his hip has near full range of motion. He still has some discomfort with flexion combined with internal rotation and adduction.DIAGNOSIS:Status post right hip arthroscopy and labral debridement, femoral and acetabuloplasty.TREATMENT:The patient is progressing well. He is cleared for jogging on a treadmill. He will continue anti-inflammatories as needed and finish out his physical therapy. He will return to the office in four to six weeks.WORK STATUS: He is going to return to a trial of full duty.Sincerely,Brandon Andrews, MDElectronically signed by BRANDON ANDREWS, MD 1/1/20XX

CaseID: OPD7267 Primary Diagnosis: Z01.818 Secondary Diagnosis: R22.1 E/M Level: 99214-57

[INDEX] MEDICAL RECORD [INDEX] OFFICE - ESTABLISHED PATIENT - PREOPSEX: Female AGE: 14DOS: 1/1/20XXCC: Pre-OpHPI:Location: knot on left side of neckQuality: worseningSeverity: moderateDuration: since birthTiming: dailyContext: when turning headModifying: nothingAssoc symptoms: growing biggerPROBLEMS: noneSURGERIES: noneMEDICATIONS: noneALLERGIES: Drug Allergies. No known.Denies surgery or anesthesia problemsFMHX:Mother- noneFather- noneSiblings- noneGrandparents- noneSOCIAL HISTORY: Lives in Coalgate, OKTOBACCO: noneALCOHOL: noneROS:gen: negative sweats, chills, fatigue, wt gain or lossneuro: negative numbness, tingling, memory changes, headaches head/neck: negative nosebleeds, hoarseness, hearing changes, tinnituscv: negative chest pain, arrythmia, leg pain/swellinggi: negative n/v, dysphagia, reflux, diarrhea, constipationpsych: negative depression, anxietyresp: negative wheezing, cough, sob, hemoptysisskin: negative sores, change in moles, rashesgu: negative burning, frequency, blood in urine, dribbling, incontinencems: negative joint swelling, joint pain, stiffness, fallsheme: negative bleeding disorders, prior transfusion, bruising, fh of bleeding disordersOBJECTIVE:VS: BMI 19.1. H: 34 in T: 97.8 F. W: 31lbs 2oz.CON: normal appearance, strong voice, face without lesions, no sinus tenderness to palpationEYES: Pupils equal, round, and reactive to light and accommodation. Conjunctiva normal.EARS: Weber and Rinne did not perform due to age. Finger rub normal bilaterally right ear with normal external ear, normal external auditory canal, tm normal with good mobility left ear with normal external ear, normal external auditory canal, tm normal with good mobilityOC/OP: mucosa, hard and soft palate, lips/teeth/gums and normal. Tonsil fossa normalHYPO/GLOTTIC: not done due to ageNECK: normal symmetry with left low scm?? Cal

CaseID: OPD7300 Primary Diagnosis: N18.4, I27.29, D64.9, I08.0, I50.9 Secondary Diagnosis: Z79.82, Z99.81 E/M Level: 99214

[INDEX] MEDICAL RECORD [INDEX] OFFICE - ESTABLISHEDSEX: Female AGE: 102Date: 01/01/20XXCHIEF CONCERN: She is here for echocardiogram and lab results.PROBLEM LIST:1. 102-year-old with recurrent congestive heart failure (20XX), secondary to severe aortic valve stenosis.2. Pulmonary Hypertension.3. Chronic renal insufficiency.4. Three months S/P gram negative sepsis complicated by acute-on-chronic renal insufficiency and acute pulmonary edema, resolved.ALLERGIES: No known drug allergies.MEDICATIONS:Metoprolol tartrate 12.5 mg b.i.d.Hydralazine 50 mg q.d.Furosemide 20 mg q.d.Amlodipine 2.5 mg q.d.Klor Con 10 mEq q.d.Oxygen at nightAspirin 81 mg q.d.INTERVAL HISTORY: The patient has been consistent in using her oxygen. She denies shortness of breath. She has had no major illnesses, accidents or falls. No chest pain. Her breathing is stable, but she is quite inactive.Echocardiogram (12/27/20XX) shows:1. Ejection fraction of 50% with normal left ventricular systolic function and grade I diastolic dysfunction.2. Severe aortic stenosis with calculated valve area of 0.4 cm.3. Mild to moderate aortic insufficiency.4. Mild mitral regurgitation.5. Mild left ventricular hypertrophy.6. Mild pulmonary hypertension at 35-40 mmHg.Labs (12/27/20XX) show:1. Hemoglobin 10.4 (improved), hematocrit 33.4.2. Fasting glucose 116.3. BUN 42, creatinine 2.01 (chronic).4. GFR 2O.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 88 lbs, BP 128/48 in the left aim, pulse 65 and regular, oxygen saturation 96% on room air.CONSTITUTIONAL: In no acute distress.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest has normal contour.CARDIOVASCULAR: Neck veins flat, grade 4/6 long aortic systolic murmur. No leg swelling.ASSESSMENT:1. Ongoing anemia, but slightly improved.2. Chronic Severe Kidney Disease Stage 4, GFR

CaseID: OPD7299 Primary Diagnosis: E03.9, E78.5 E/M Level: 99213

[INDEX] MEDICAL RECORD [INDEX] OFFICE - ESTABLISHEDSEX: Female AGE: 57Date: 01/01/20XXCHIEF CONCERN: She is here for a four-month checkup.PROBLEM LIST:1. 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, pulse 63 and regular, oxygen saturation 95% on room air.CONSTITUTIONAL: In no acute distress.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis.RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest has normal contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 and normal. No murmur, clicks or gallops. Abdominal aorta not palpable, no bruit. Femoral, tibial, dorsalis pedis pulses intact. No leg swelling.GASTROINTESTINAL: Abdomen: Soft. Positive BS x4 quads. No masses or tenderness. No hepatosplenomegaly.SKIN: Pink, warm and dry. Skin intact. No rashes. No lesions. No clubbing or cyanosis.NEUROLOGIC/PSYCH: Cranial nerves II-XII grossly intact. Alert and oriented x3. Affect normal.ASSESSMENT:1. Hypothyroidism on Cytomel2. Hyperlipidem

CaseID: OPD7301 Primary Diagnosis: I11.9 Secondary Diagnosis: Z79.02 E/M Level: 99213

[INDEX] MEDICAL RECORD [INDEX] OFFICE - ESTABLISHEDSEX: Female AGE: 79Date: 01/01/20XXCHIEF CONCERN: She is here for medication check.PROBLEM LIST: 1. 79 y/o Caucasian 1+ years S/P atrial fibrillation with rapid ventricular response associated hypotension requiring emergency DC cardioversion.2. Sinus bradycardia to 38 on metoprolol, now discontinued.3. Two months S/P pneumonia.4. Hypertension.5. Moderately severe left ventricular hypertrophy associated with hyperkinetic left ventricle and inducible limited left ventricular outflow tract obstruction.6. COPD with asthma (hospitalization for exacerbation three months ago).7. Branch coronary disease; per angiography; she had 75% proximal and 90-95% distal medium size diagonal branch stenosis. Otherwise, normal coronary arteriogram.8. 5 years S/P multiple CVA with residual right hemiparesis and right ocular visual disturbance secondary to reported retinal RE occlusion.9. History of hyperlipidemia.10. Hypothyroidism, on replacement treatment.11. History of seizures reportedly secondary to CVAs.12. Borderline platelet inhibition and subtherapeutic aspirin and Plavix affect with the above history.13. Significant back pain, secondary to arthritis and spinal stenosis, which limits her activity.ALLERGIES: Penicillin, sulfa.MEDICATIONS:Levothyroxine 150 mcg q.d.Ferrous sulfate 5 g b.i.d.Prilosec 20 mg q.d.Multaq 400 mg b.i.d.Losartan 100 mg q.d.Lexapro 10 mg q.d.Plavix 75 mg q.d.B12 1000 mcg q.d.Crestor 20 mg q.d.Micro-K 20 mEq b.i.d.Imdur 30 mg q.d.Mag Ox 500 mg q.d.1 eye vitamins b.i.d.Colace 100 mg q.d.Depakote 500 mg h.s.Baby aspirin 81 mg q.d.Meclizine 25 mg p.r.n. Multivitamins q.d.HCTZ 25 mg q.d.Cod liver oilINTERVAL HISTORY: Since last office visit, the patient presented to the hospital for chest pain. Her Imdur was re-started, and she has had no further chest pain. No sho

CaseID: OPD7298 Primary Diagnosis: G47.30, R41.3 Secondary Diagnosis: Z79.01, Z95.0 E/M Level: 99213

[INDEX] MEDICAL RECORD [INDEX] OFFICE - ESTABLISHEDSex: F AGE 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. Presyncope 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 patient obtained her CPAP machine approximately five days ago and is using as prescribed. She feels her memory may be somewhat improved over the last several days but continues to be worrisome to her. She has had no chest pain. Her breathing is stable.PHYSICAL EXAMINATION:VITAL SIGNS: Weight 161 lbs, BP 110/60 (lg. cuff) in the left arm, pulse 69 and regular, oxygen saturation 91% on room air.CONSTITUTIONAL: She has poor recollection of recent events and simple medical details, such as being aware she has a pacemaker.HEENT: Eyes: No xanthelasma or exophthalmos. No arcus senilis. Tongue midline. Mucous membranes moist, with no cyanosis RESPIRATORY: Respirations even and unlabored. Good air entry bilaterally. No adventitious sounds. Chest has normal contour.CARDIOVASCULAR: PMI normal. Neck veins flat. No carotid bruits. S1, S2 and normal. No murmur clicks or gallops. Abdominal aorta