E&M AND MEDICINE QUESTIONS AND
ANSWERS 2026-2027
EstablishedkPatientkOfficekVisitk|1|kPatientkherektodaykbecausekof kakfootballkinjury,kparentkthoughtkitkwoul
dkgetkbetter.kPatientkhaskproblemkwithkhiskrightkshoulder.kHe kwasktackledkinkfootballkpractice kandklandedko
nkshoulder.kSubjectivekCC:kShoulderkinjurykHPI:kHaskpainkinkthe krightkshoulderksincekakfootballktackle.k|2|kR
OSkConst:kDenieskchills,kfatigue,kfever,kandkweightkchange.kGeneralkhealthkstatedkaskgood.kEyes:kDenieskvis
ual kdisturbance.kCV:kDenieskchestkpainkandkpalpitations.kResp:kDenieskcough,kdyspnea,kandkwheezing.kGI:k
Denieskconstipation,kdiarrhea.kDyspepsia.kdysphagia,khematochezia.kMelena,knausea,kandkvomiting.kGU:k
Urinary:kdenieskdysuria.kFrequency,khematuria,kincontinence.kMusculo:kDenieskarthralgias,kandkmyalgia.kS
kin:kDenieskrashes.kNeuro:kDenieskneurologicksymptoms.kCurrentkMeds:kNonekAllergies:kNKDAkObjectivekB
P:k118/78kPulse;k76kT:k98.0kExamkConst:kAppearskobese.kNoksignskofkapparentkdistresskpresk-
kCORRECTkANSWER-99213kICD-10-CMkCode:kM25.511
EstablishedkPatientkOfficekVisitk|1|kChief kComplaint:kRightkshoulderkpaink|2|kThiskiskak47-year-
old,kotherwisekhealthy,kright-hand-dominantkmalektoolkmakerkwithkak6-
8kweekkhistorykofkgradual kinsidiouskonsetkofkrightkshoulderkpain.kHekhasknotedkpoppingkalongkthekmedialka
spectkofkthe kscapula,kbutkthiskisknotkparticularlykassociatedkwithkthekpain.kThekpainkseemsktokbeklocalizedk
more klaterally.kHekhaskbeenktakingkNaprosynkforksomeklowkbackkdiscomfort,kwhichkhelpskhiskshoulderkaskw
ell.k|3|kROS:kNokHEENT,krespiratory,kcardiovascular,kgastrointestinal,kgenitourinary,korknervekcomplaints.k
MSkiskpositivekforkjointkpain,kmusclektenderness,kandkweakness.kPastkHistory:kMedications:kNaprosyn,kAlle
rgicktokPenicillin.kPriorksurgerykonklowerkbackk(1994).kSocialkHistory:kpositivekforktobaccokandkalcoholkuse.k
Physical kExamination:kRightkshoulderkisknon-
swollen.kNokdeformity.kNokmuscularkatrophy.kHekdoeskhave kcrepituskthatklocalizesktok-kCORRECTkANSWER-
99213-25,k20610,km75.81
HISTORYkANDkPHYSICALkADMITkDATE:k4/10/20XXkCHIEFkCOMPLAINT:kNauseakandkdiaphoresisktimeskonek
dayk|1|.kHISTORYkOFkPRESENTkILLNESS:kThiskiskak69-year-
oldkmale kwithkakpastkmedical khistorykofkcoronarykarterykdisease,kdiabeteskandkhyperlipidemiak|2|.kHekstat
eskhe kwaskatkthekAthletickCenterkandkate kdinnerk|3|katkapproximatelyk5kp.m.k|4|kHekwentktokthekbasketbal
l kgame;kaskhe kwaskwatching,khekfeltknauseatedk|5|.kHekwentktokthekbathroomkandkfeltkcoldksweats.kHekwe
ntkhome kandkhadknausea.kHe kcalledkEMSA.kHekwaskfoundktokbektachycardick|6|.kHe kwaskbroughtktokthekem
ergencykroom.kHe khaskcontinuedktokbektachycardickinkthe kemergencykroom.kTherekhaskbeenknokrecentktrav
el kbutkpositivekrecentkstressk|7|.kTherekisknokvomiting,kdiarrheakorkpalpitationsk|8|.kTherekare knokalleviatin
gkorkaggravatingkfactorsk|9|.kHe kreportskhekfeelskmuchkbetterknowk|10|kbutkhekdoeskcontinuektokhave ktac
hycardickonkthe ktelemetrykmonitor.kPASTkMEDICALkHISTORYk1k-kCORRECTkANSWER-99219kICD-10-
CMkCodes:kR00.0,kE11.9,kE78.5,kZ79.84
,Admissionkdiagnosis:kPelvickpaink|1|,kprobable kpelvickinflammatorykdisease;krule koutkectopic;krulekoutkapp
endicitis.kHistory:kThiskestablishedkpatientkiskak37ky.o.kG3kP1012kwhite kfemalekseenkinkthekoffice kthiskaftern
oonkforkrecentkonsetk|2|kof kakfoulk|3|kdischargek|4|kandkpelvickpaink|5|.kLMPkwask5kweekskagok|6|,kshe kisk
oftenkirregular.kShe kreportsk7kdayskagokhavingkrelationskwithkherkformerkpartnerkonkconsecutivekdays.k3kto
k4kdayskfollowingkthe kweekend, kshe knoted kthekgradualkonsetkof kakfoulksmellingkyellow-
greenkdischargekandkcrampingk|7|.kOverktheksubsequentk3kdaysk|8|kthiskdischargekhaskincreasedk|9|krequ
iringkakperi-
pad.kShe khaskhadktokchange kthekpadkqkhour.kShekhaskalsoknotedkthekincreasekinkpelvickandklowerkabdomina
l kpainkandkcrampingk|10|.kThe kpainkiskworsekthankherknormalkmenstrualkcrampsk|11|,knotkhelpedkwithkthe
kapplication kofkheatk|12|. kTherekwaskinitially kaksmallkimprovementkwithkoral kibuprofen k|13|;kitkhk-
kCORRECTkANSWER-99221kICD-10-CMkCode:kN73.9
HISTORYk&kPHYSICALkAdmitkDate:k11/05/20XXkCHIEFkCOMPLAINT:kAbdominalkpain,kdiarrheak|1|.kHISTOR
YkOFkPRESENTkILLNESSkThe kpatientkiskak86-year-
oldkCaucasiankfemale kwhokhaskakknownkhistorykofkdiverticulosiskandkhaskhadkseveralkepisodeskofkdiverticul
itiskinkthekpast.kShekstateskthatkshekfollowskakBRATkdietk|2|ktryingktokavoidkproblemskbutkstateskshekhaskbe
enkdealingkwithkthiskepisode knowkforkaboutktwokdaysk|3|,kthiskhasknotkbeenkgettingkanykbetterkandkshe khas
kbeen kgettingkincreasingk|4|kabdominalkpainkandkcrampingkinkthekleftklowerksidek|5|. kHasktakenkImodium®
kwhichkhaskhelpedkwithkthe kdiarrheak|6|. kDoeskmention kthatkshekhaskbeenkonkakrecentkcoursekofkpredniso
ne kandkmeclizine kbykDr.kXkforkankepisode kofkvertigokwhichkseemsktokhave kimprovedksome.kShekhasknotksee
nkanykbloodkinkherkstool.kShe khasknotkhadkanykfever,kchills;kprimarilykjustkthekpainkandkdiarrheak|7|.kPASTk
MEDICALkHISTORYk1.kCVAkwithkmemoryklosskiskthekonlyksequk-kCORRECTkANSWER-:k99221kICD-10-
CMkCodes:kK52.9,kE86.0
Chief kComplaint:kDizziness,knausea,kvomiting.kHistorykof kPresentkIllness:kAk43-year-
oldkverykpleasantkgentlemankwithkhistorykofkhypertensionkwhokpresentsktokthe kemergencykroomkwithkchie
fkcomplaintkof kabruptkonsetkofknausea,kvomiting,kandkdizziness.kThe kpatientksaidkthatkwhilekhekwasksittingk
he kfeltklikekthekroomkwaskspinning,khekfeltkverykunstable,kassociatedkwithksevereknausea.kDenieskanykabdo
minal kpain,kfever,kchills,kheadache,korkshortnesskofkbreath.kSymptomskarekexacerbatedkbykcertainkmovem
ents.kDenieskanyksickkcontacts.kThiskiskthe kfirstktime kthiskhaskeverkhappened.kThekpatientkarrivedkviakEMS.k
Afterkreceivingk12.5kmgkofkPhenergan®kintravenously,khe kfeelskbetterkatkthisktime.kThekpatientksaidkthatkhe
khasksome kmildknausea.kHe khaskhadkone kepisode kof knonbloody, knonbilious kemesiskinkthekemergency kroom.
kPastkMedical kHistory:kHypertension. kPastkSurgicalkHistory:kNegative. kSocialkHistory:kOccasional kuse,knons
moker,knok-kCORRECTkANSWER-CPT®kCodes:k99284kICD-10-CMkCode:kR42
PatientkinkICUkCC:kMulti-
systemkorgankfailurek|1|kINTERVALkHISTORY:kPatientkiskak65ky/okfemalekwhokremainskintubatedkandksedat
ed.kOvernightkeventskreviewed.kToleratingktubekfeeds.kSystolickpressureskhavekbeenkrunningkinkthe klowk90
skonkLEVOPHED.kCultureskremainknegative.kKidneykfunctionkhaskworsenedk|2|,kbutkpatientkremainsknon-
oliguric.kPHYSICALkEXAM:k96/60,k112,k100.8.kLungskhave kanteriorkrhonchi.kHeartkRRRkwithknokMRGs.kAbdo
menkisksoftkwithkpositivekbowel ksounds.kExtremitieskshowkmoderate kedema.kLABS:kBUNk89,kcreatininek2.6,
, kHGBk10.2,kWBCk22,000.kABG:k7.34/100/42konk50%kFiO2.kCXRkshowskRLLkinfiltrate.kIMPRESSIONk1.kHypoxic
kacute krespiratory kfailurek|3|k2. kCommunity kacquired kpneumoniak3. kSeptickshock k|4|k4. kNon-
oligurickacute krenal kfailurek|5|kPLAN:kContinuekNSkatk75kcc/hr.kDecrease kZOSYNktok2.25kgramskIV kQk6HkFoll
owkcultures.kContinuektubekfeeds.kTitratekLEVOPHEDktokmaintainkSBPk>k90kUsual klabskorderedkforktomorro
wk-kCORRECTkANSWER-:k99291kICD-10-CMkCodes:kA41.9,kR65.21,kJ96.01,kN17.9,kJ18.9
Place kofkService:kLongktermkcare kfacilityk|1|kMaritalkStatus:kMarriedkPowerkofkAttorneykIkHealthkProxy:kYes
kSource kof khistory:kPatientkandkreliabilityklow kofkhistorian.kChiefkComplaint:kLongkTermkCare kPlacementk|2
|kHistorykofkpresentkillness:k85kY/OkWMkiskhere ktokstaykinkLkTermkPt'skfamilykhaskfoundkthatkpatientkandkhisk
wife kare knotkablektoktake kcarekof kthemselveskatkhome k|3|.kLivingksituationkiskdeterioratingkandkgettingkwor
se k|4|.kDaughterkhaskbeenkherekandkhusbandkhaskrecentlykjoinedkher.kPatientkandkhiskwifekwishktokgokback
khome. kHoweverktheirkhistory kiskcomplicated kbykthekfactkthatktheykhavekchronickpainksyndromeskforkmany k
yearsk|5|kandkhave kbeenkonkMethadone.kHavingkmemorykissuesk|6|.kTheykalsokhavekbeenkabusingkalcohol
kandkhaskhadkmultiplekproblemskduektokit. kAllergies:kNKDAkMedications:kReviewed. kPMH:kOA, kDepression,k
Renal kCellkCakS/PkLknephrectomy.kChronickpainksyndrome.kBPH,kCKDkII,k|7|kPSHx:klktotalkKneekak-
kCORRECTkANSWER-G89.4, kF03.90, kF10.10
SubsequentkVisitkPlace kofkService:kSkilledknursingkfacilitykMaritalkStatus:kWidowedkPowerkofkAttorneykIkHe
althkProxy:kYeskSourcekofkhistorykPatientkandkreliabilitykhighkofkhistorian.kS:k1.kEdema/SOB:kPtkhaskhxkof kCA
D,kMVPkandktricuspidkinsufficiency.kIkstartedkptkonkLasix kandkherkedemakandklegkswellingkiskbetter.kCoughka
ndkSOBkiskalsokimproving.kPTkfeelskgood.kPressurekUlcer:kOnkcoccyx khealingkwell.kWoundkcare knurse kiskonkb
oard.kAllergies:kLOPRESSORk(Shortnesskofkbreath),kLORTABk(Doesn'tkremember),kPREVACIDk(Doesn'tkreme
mber),kPROCARDIA k(Doesn'tkremember).kMedicationskreviewed.kPastkMedical kHistorykTRICUSPIDkINSUFFI
C,kMITRALkVALVEkPROLA,kDIVERTICULITIS,kHYPERTENSION,kHYPERLIPIDEMIA kNOS,kCAD,kOSTEOPOROSISkN
OS,kCOLONkPOLYPS,kCARDIACkARRHYTHMIAkSurgeries:k1.kHysterectomykink19XX.k3.kChondroplastykofkthekr
ightkknee kink20XX.k5.kLeftktotalkkneekreplacementk-
k20XX kFamily kHistory:kFatherkdiedkof ktuberculosis.kMotherkhadkthyrk- kCORRECTkANSWER-99309kICD-10-
CMkCodes:kR60.9,kI10,kL89.152
Location:kABCkRetirementkHomeskReasonkforkAppointment:k1.kMonitorkprogresskandkassesskneedskofkchro
nickconditionsk|1|.kCurrentkMedications:kJanuviak50kMGkTabletk1ktabletkOnce kakdaykLantusk100kUNITk/MLk
Solutionk0.02kml kOncekakdaykLevothyroxine kSodiumk175kmegkTabletk1ktabletkonkankemptykstomachkinkthek
morningkOnce kakdaykOmeprazole k40kMGkCapsulekDelayedkReleasek1kcapsulekOnce kakdaykPravastatinkSodiu
mk40kMGkTabletk1ktabletkOnce kakdaykNateglinide k120kMGkTabletk1ktabletkbefore kmealskThree ktimeskakdaykP
randink1kMGkTabletk1ktabletk15ktok30kminuteskbefore kmealskThree ktimeskakdaykDiltiazemkHC130kMGkTablet
k1ktabletkbeforekmealskandkatkbedtimekFourktimes kakday kClonazepamk0.5kMGkTabletk1ktabletkatkbedtimekEv
eryk8khrskPRNkTemazepamk15kMGkCapsulek1kcapsulekatkbedtimekaskneededkonce kakdaykprnkTramadol kHClk5
0kMGkTabletk1ktabletkaskneededkeveryk6khrskPastkMedicalkHistoryk|2|:kDiabeteskmellitus,kDementia,kCVD,kC
HF,kCOPD,kCVA,kHypothyrok-kCORRECTkANSWER-:k99335kICD-10-
CMkCodes:kE11.9,kR30.0,kM62.81,kJ44.9,kE78.5,kF03.90
ANSWERS 2026-2027
EstablishedkPatientkOfficekVisitk|1|kPatientkherektodaykbecausekof kakfootballkinjury,kparentkthoughtkitkwoul
dkgetkbetter.kPatientkhaskproblemkwithkhiskrightkshoulder.kHe kwasktackledkinkfootballkpractice kandklandedko
nkshoulder.kSubjectivekCC:kShoulderkinjurykHPI:kHaskpainkinkthe krightkshoulderksincekakfootballktackle.k|2|kR
OSkConst:kDenieskchills,kfatigue,kfever,kandkweightkchange.kGeneralkhealthkstatedkaskgood.kEyes:kDenieskvis
ual kdisturbance.kCV:kDenieskchestkpainkandkpalpitations.kResp:kDenieskcough,kdyspnea,kandkwheezing.kGI:k
Denieskconstipation,kdiarrhea.kDyspepsia.kdysphagia,khematochezia.kMelena,knausea,kandkvomiting.kGU:k
Urinary:kdenieskdysuria.kFrequency,khematuria,kincontinence.kMusculo:kDenieskarthralgias,kandkmyalgia.kS
kin:kDenieskrashes.kNeuro:kDenieskneurologicksymptoms.kCurrentkMeds:kNonekAllergies:kNKDAkObjectivekB
P:k118/78kPulse;k76kT:k98.0kExamkConst:kAppearskobese.kNoksignskofkapparentkdistresskpresk-
kCORRECTkANSWER-99213kICD-10-CMkCode:kM25.511
EstablishedkPatientkOfficekVisitk|1|kChief kComplaint:kRightkshoulderkpaink|2|kThiskiskak47-year-
old,kotherwisekhealthy,kright-hand-dominantkmalektoolkmakerkwithkak6-
8kweekkhistorykofkgradual kinsidiouskonsetkofkrightkshoulderkpain.kHekhasknotedkpoppingkalongkthekmedialka
spectkofkthe kscapula,kbutkthiskisknotkparticularlykassociatedkwithkthekpain.kThekpainkseemsktokbeklocalizedk
more klaterally.kHekhaskbeenktakingkNaprosynkforksomeklowkbackkdiscomfort,kwhichkhelpskhiskshoulderkaskw
ell.k|3|kROS:kNokHEENT,krespiratory,kcardiovascular,kgastrointestinal,kgenitourinary,korknervekcomplaints.k
MSkiskpositivekforkjointkpain,kmusclektenderness,kandkweakness.kPastkHistory:kMedications:kNaprosyn,kAlle
rgicktokPenicillin.kPriorksurgerykonklowerkbackk(1994).kSocialkHistory:kpositivekforktobaccokandkalcoholkuse.k
Physical kExamination:kRightkshoulderkisknon-
swollen.kNokdeformity.kNokmuscularkatrophy.kHekdoeskhave kcrepituskthatklocalizesktok-kCORRECTkANSWER-
99213-25,k20610,km75.81
HISTORYkANDkPHYSICALkADMITkDATE:k4/10/20XXkCHIEFkCOMPLAINT:kNauseakandkdiaphoresisktimeskonek
dayk|1|.kHISTORYkOFkPRESENTkILLNESS:kThiskiskak69-year-
oldkmale kwithkakpastkmedical khistorykofkcoronarykarterykdisease,kdiabeteskandkhyperlipidemiak|2|.kHekstat
eskhe kwaskatkthekAthletickCenterkandkate kdinnerk|3|katkapproximatelyk5kp.m.k|4|kHekwentktokthekbasketbal
l kgame;kaskhe kwaskwatching,khekfeltknauseatedk|5|.kHekwentktokthekbathroomkandkfeltkcoldksweats.kHekwe
ntkhome kandkhadknausea.kHe kcalledkEMSA.kHekwaskfoundktokbektachycardick|6|.kHe kwaskbroughtktokthekem
ergencykroom.kHe khaskcontinuedktokbektachycardickinkthe kemergencykroom.kTherekhaskbeenknokrecentktrav
el kbutkpositivekrecentkstressk|7|.kTherekisknokvomiting,kdiarrheakorkpalpitationsk|8|.kTherekare knokalleviatin
gkorkaggravatingkfactorsk|9|.kHe kreportskhekfeelskmuchkbetterknowk|10|kbutkhekdoeskcontinuektokhave ktac
hycardickonkthe ktelemetrykmonitor.kPASTkMEDICALkHISTORYk1k-kCORRECTkANSWER-99219kICD-10-
CMkCodes:kR00.0,kE11.9,kE78.5,kZ79.84
,Admissionkdiagnosis:kPelvickpaink|1|,kprobable kpelvickinflammatorykdisease;krule koutkectopic;krulekoutkapp
endicitis.kHistory:kThiskestablishedkpatientkiskak37ky.o.kG3kP1012kwhite kfemalekseenkinkthekoffice kthiskaftern
oonkforkrecentkonsetk|2|kof kakfoulk|3|kdischargek|4|kandkpelvickpaink|5|.kLMPkwask5kweekskagok|6|,kshe kisk
oftenkirregular.kShe kreportsk7kdayskagokhavingkrelationskwithkherkformerkpartnerkonkconsecutivekdays.k3kto
k4kdayskfollowingkthe kweekend, kshe knoted kthekgradualkonsetkof kakfoulksmellingkyellow-
greenkdischargekandkcrampingk|7|.kOverktheksubsequentk3kdaysk|8|kthiskdischargekhaskincreasedk|9|krequ
iringkakperi-
pad.kShe khaskhadktokchange kthekpadkqkhour.kShekhaskalsoknotedkthekincreasekinkpelvickandklowerkabdomina
l kpainkandkcrampingk|10|.kThe kpainkiskworsekthankherknormalkmenstrualkcrampsk|11|,knotkhelpedkwithkthe
kapplication kofkheatk|12|. kTherekwaskinitially kaksmallkimprovementkwithkoral kibuprofen k|13|;kitkhk-
kCORRECTkANSWER-99221kICD-10-CMkCode:kN73.9
HISTORYk&kPHYSICALkAdmitkDate:k11/05/20XXkCHIEFkCOMPLAINT:kAbdominalkpain,kdiarrheak|1|.kHISTOR
YkOFkPRESENTkILLNESSkThe kpatientkiskak86-year-
oldkCaucasiankfemale kwhokhaskakknownkhistorykofkdiverticulosiskandkhaskhadkseveralkepisodeskofkdiverticul
itiskinkthekpast.kShekstateskthatkshekfollowskakBRATkdietk|2|ktryingktokavoidkproblemskbutkstateskshekhaskbe
enkdealingkwithkthiskepisode knowkforkaboutktwokdaysk|3|,kthiskhasknotkbeenkgettingkanykbetterkandkshe khas
kbeen kgettingkincreasingk|4|kabdominalkpainkandkcrampingkinkthekleftklowerksidek|5|. kHasktakenkImodium®
kwhichkhaskhelpedkwithkthe kdiarrheak|6|. kDoeskmention kthatkshekhaskbeenkonkakrecentkcoursekofkpredniso
ne kandkmeclizine kbykDr.kXkforkankepisode kofkvertigokwhichkseemsktokhave kimprovedksome.kShekhasknotksee
nkanykbloodkinkherkstool.kShe khasknotkhadkanykfever,kchills;kprimarilykjustkthekpainkandkdiarrheak|7|.kPASTk
MEDICALkHISTORYk1.kCVAkwithkmemoryklosskiskthekonlyksequk-kCORRECTkANSWER-:k99221kICD-10-
CMkCodes:kK52.9,kE86.0
Chief kComplaint:kDizziness,knausea,kvomiting.kHistorykof kPresentkIllness:kAk43-year-
oldkverykpleasantkgentlemankwithkhistorykofkhypertensionkwhokpresentsktokthe kemergencykroomkwithkchie
fkcomplaintkof kabruptkonsetkofknausea,kvomiting,kandkdizziness.kThe kpatientksaidkthatkwhilekhekwasksittingk
he kfeltklikekthekroomkwaskspinning,khekfeltkverykunstable,kassociatedkwithksevereknausea.kDenieskanykabdo
minal kpain,kfever,kchills,kheadache,korkshortnesskofkbreath.kSymptomskarekexacerbatedkbykcertainkmovem
ents.kDenieskanyksickkcontacts.kThiskiskthe kfirstktime kthiskhaskeverkhappened.kThekpatientkarrivedkviakEMS.k
Afterkreceivingk12.5kmgkofkPhenergan®kintravenously,khe kfeelskbetterkatkthisktime.kThekpatientksaidkthatkhe
khasksome kmildknausea.kHe khaskhadkone kepisode kof knonbloody, knonbilious kemesiskinkthekemergency kroom.
kPastkMedical kHistory:kHypertension. kPastkSurgicalkHistory:kNegative. kSocialkHistory:kOccasional kuse,knons
moker,knok-kCORRECTkANSWER-CPT®kCodes:k99284kICD-10-CMkCode:kR42
PatientkinkICUkCC:kMulti-
systemkorgankfailurek|1|kINTERVALkHISTORY:kPatientkiskak65ky/okfemalekwhokremainskintubatedkandksedat
ed.kOvernightkeventskreviewed.kToleratingktubekfeeds.kSystolickpressureskhavekbeenkrunningkinkthe klowk90
skonkLEVOPHED.kCultureskremainknegative.kKidneykfunctionkhaskworsenedk|2|,kbutkpatientkremainsknon-
oliguric.kPHYSICALkEXAM:k96/60,k112,k100.8.kLungskhave kanteriorkrhonchi.kHeartkRRRkwithknokMRGs.kAbdo
menkisksoftkwithkpositivekbowel ksounds.kExtremitieskshowkmoderate kedema.kLABS:kBUNk89,kcreatininek2.6,
, kHGBk10.2,kWBCk22,000.kABG:k7.34/100/42konk50%kFiO2.kCXRkshowskRLLkinfiltrate.kIMPRESSIONk1.kHypoxic
kacute krespiratory kfailurek|3|k2. kCommunity kacquired kpneumoniak3. kSeptickshock k|4|k4. kNon-
oligurickacute krenal kfailurek|5|kPLAN:kContinuekNSkatk75kcc/hr.kDecrease kZOSYNktok2.25kgramskIV kQk6HkFoll
owkcultures.kContinuektubekfeeds.kTitratekLEVOPHEDktokmaintainkSBPk>k90kUsual klabskorderedkforktomorro
wk-kCORRECTkANSWER-:k99291kICD-10-CMkCodes:kA41.9,kR65.21,kJ96.01,kN17.9,kJ18.9
Place kofkService:kLongktermkcare kfacilityk|1|kMaritalkStatus:kMarriedkPowerkofkAttorneykIkHealthkProxy:kYes
kSource kof khistory:kPatientkandkreliabilityklow kofkhistorian.kChiefkComplaint:kLongkTermkCare kPlacementk|2
|kHistorykofkpresentkillness:k85kY/OkWMkiskhere ktokstaykinkLkTermkPt'skfamilykhaskfoundkthatkpatientkandkhisk
wife kare knotkablektoktake kcarekof kthemselveskatkhome k|3|.kLivingksituationkiskdeterioratingkandkgettingkwor
se k|4|.kDaughterkhaskbeenkherekandkhusbandkhaskrecentlykjoinedkher.kPatientkandkhiskwifekwishktokgokback
khome. kHoweverktheirkhistory kiskcomplicated kbykthekfactkthatktheykhavekchronickpainksyndromeskforkmany k
yearsk|5|kandkhave kbeenkonkMethadone.kHavingkmemorykissuesk|6|.kTheykalsokhavekbeenkabusingkalcohol
kandkhaskhadkmultiplekproblemskduektokit. kAllergies:kNKDAkMedications:kReviewed. kPMH:kOA, kDepression,k
Renal kCellkCakS/PkLknephrectomy.kChronickpainksyndrome.kBPH,kCKDkII,k|7|kPSHx:klktotalkKneekak-
kCORRECTkANSWER-G89.4, kF03.90, kF10.10
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althkProxy:kYeskSourcekofkhistorykPatientkandkreliabilitykhighkofkhistorian.kS:k1.kEdema/SOB:kPtkhaskhxkof kCA
D,kMVPkandktricuspidkinsufficiency.kIkstartedkptkonkLasix kandkherkedemakandklegkswellingkiskbetter.kCoughka
ndkSOBkiskalsokimproving.kPTkfeelskgood.kPressurekUlcer:kOnkcoccyx khealingkwell.kWoundkcare knurse kiskonkb
oard.kAllergies:kLOPRESSORk(Shortnesskofkbreath),kLORTABk(Doesn'tkremember),kPREVACIDk(Doesn'tkreme
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OS,kCOLONkPOLYPS,kCARDIACkARRHYTHMIAkSurgeries:k1.kHysterectomykink19XX.k3.kChondroplastykofkthekr
ightkknee kink20XX.k5.kLeftktotalkkneekreplacementk-
k20XX kFamily kHistory:kFatherkdiedkof ktuberculosis.kMotherkhadkthyrk- kCORRECTkANSWER-99309kICD-10-
CMkCodes:kR60.9,kI10,kL89.152
Location:kABCkRetirementkHomeskReasonkforkAppointment:k1.kMonitorkprogresskandkassesskneedskofkchro
nickconditionsk|1|.kCurrentkMedications:kJanuviak50kMGkTabletk1ktabletkOnce kakdaykLantusk100kUNITk/MLk
Solutionk0.02kml kOncekakdaykLevothyroxine kSodiumk175kmegkTabletk1ktabletkonkankemptykstomachkinkthek
morningkOnce kakdaykOmeprazole k40kMGkCapsulekDelayedkReleasek1kcapsulekOnce kakdaykPravastatinkSodiu
mk40kMGkTabletk1ktabletkOnce kakdaykNateglinide k120kMGkTabletk1ktabletkbefore kmealskThree ktimeskakdaykP
randink1kMGkTabletk1ktabletk15ktok30kminuteskbefore kmealskThree ktimeskakdaykDiltiazemkHC130kMGkTablet
k1ktabletkbeforekmealskandkatkbedtimekFourktimes kakday kClonazepamk0.5kMGkTabletk1ktabletkatkbedtimekEv
eryk8khrskPRNkTemazepamk15kMGkCapsulek1kcapsulekatkbedtimekaskneededkonce kakdaykprnkTramadol kHClk5
0kMGkTabletk1ktabletkaskneededkeveryk6khrskPastkMedicalkHistoryk|2|:kDiabeteskmellitus,kDementia,kCVD,kC
HF,kCOPD,kCVA,kHypothyrok-kCORRECTkANSWER-:k99335kICD-10-
CMkCodes:kE11.9,kR30.0,kM62.81,kJ44.9,kE78.5,kF03.90
