Practicode Set 1-200
Study online at https://quizlet.com/_etzafu
1. RADIOLOGY REPORT Location: AAPC Family Practice
Sex: MAGE: 31DATE OF EXAM: 1/01/20XXREFERRED BY PHYSICIAN(S): M.D.PRO-
CEDURE: X-RAY ABDOMEN/KUB SUPINE, ONE VIEWCOMPARISON: None.I NDI-
CATIONS: Abdomen pain. History of stones. TECHNIQUE: A single AP supine
view of the abdomen was performed. FINDINGS:BOWEL GAS PATTERN: Nor-
mal. CALCIFICATIONS: None signi�cant. OTHER: Normal for age. CONCLUSION:
1. NORMAL EXAM. NO KIDNEY STONES IDENTIFIED. Electronically signed by
1/1/20XX
Case ID : OPD7029: R10.9 Unspeci�ed abdominal pain
Z87.442 Personal history of urinary calculi
740181 Radiologic Exam Abdomen 1 View
2. OFFICE - ESTABLISHED Sex: FAGE 71Date: 01/01/20XXCHIEF CONCERN: She
is here for follow up of CPAP titration. PROBLEM LIST:1. A female with VVI
pacemaker replacement (20XX), for chronic atrial �brillation with intermittent
high grade A-V block and uncontrolled ventricular rate.2. Recurrent heart fail-
ure associated with atrial �brillation with rapid ventricular response.3. Recur-
rent deep venous thrombosis with a Green�eld vena cava �lter placed, on
maintenance Coumadin.4. Remote history of pulmonary embolism.5. Presyn-
copal 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 o ce visit, the pa: G47.30 Sleep apnea, unspeci�ed
R41.3 Other amnesia
Z79.01 Long term (current) use of anticoagu
99213 O ce/outpatient Established Low Md
3. OPERATIVE REPORTAGE: 39DOS: 1/1/20XXPHYSICIAN: Carrol Andrews, MD-
PREOPERATIVE DIAGNOSIS: Bilateral macromastia (hypertrophy).POSTOPER-
ATIVE DIAGNOSIS: Bilateral macromastia (hypertrophy).OPERATIVE PROCE-
DURE: Bilateral reduction mammoplasty. SURGEON: Carrol Andrews, MDANES-
, Practicode Set 1-200
Study online at https://quizlet.com/_etzafu
THESIA: 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 signi�cant macromastia where
I explained that this goal would be easily achieved. The patient agreed and
wished to proceed with surgery. DESCRIPTION OF PROCEDURE: The patient
was brought to the operating room where she was placed in supine position.
She was placed under general anesthesia. Bilateral upper extremities were
secured to arm boards with cast padding. Both breasts were marked in: N62
Hypertrophy of breast
193181 mod:50 Breast Reduction
4. OFFICE - ESTABLISHED SEX: FEMALEAGE: 69DOS: 1/1/20XXCHIEF COMPLAINT:
Bilateral back pain, muscle pain. HPI: Back Pain: Reported by Patient: Locations:
pain radiating to the buttocks; pain radiating to the legs. Quality: sharp. Severi-
ty: 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; exing back; extending back. Associ-
ated 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: Re-
viewed Medications: ADVAIR DISKUSATENOLOL 100 MG TABFENTANYLFLUTI-
CASONEHYDROCODONE 10 MG TABLY: E87.6 Hypokalemia
M51.36 Other intervertebral disc degenerative
99213 O ce/outpatient Established Low Md
5. OFFICE VISIT - EST Sex: MAGE: 44DOS: 1/1/20XXSUBJECTIVE: The patient is
a male being seen for lumbar back pain. The symptoms have been gradual
in onset with a severity of 6/10 in pain score. This lumbar back pain is also
associated with headaches. Both sides are a ected equally. He has had no
history of surgery .OBJECTIVE: On exam, he has di use lower lumbar back pain
and headache PLAN: The patient will need a lumbar AP and lateral plain �lm
, Practicode Set 1-200
Study online at https://quizlet.com/_etzafu
for further evaluation. Patient to return to o ce after obtaining further studies
or if symptoms get worse David Kramer, MD Electronically signed by DAVID
KRAMER, MD 1/1//20XX
Case ID : OPD7206: M54.50 Low back pain, unspeci�ed
R51.9 Headache, unspeci�ed
6. SEX: MALEAGE: 75DOS: 1/1/20XXPHYSICIAN: Sidney Jones, MDPREOPERA-
TIVE DIAGNOSIS: Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS:
Left carpal tunnel syndrome. OPERATIVE PROCEDURE: Left endoscopic carpal
tunnel release. SURGEON: Sidney Jones, MDANESTHESIA: General. COMPLI-
CATIONS: None. INDICATIONS: The patient a male who presented to clin-
ic with left hand paresthesias in the median nerve distribution. Symptoms
failed to improve with conservative management. Therefore, I recommended
left endoscopic carpal tunnel release. The patient agreed, understanding the
risks of nerve injury, tendon injury, persistent symptoms, recurrent symptoms,
and need for further surgery. DESCRIPTION OF PROCEDURE: The patient was
brought to the operating room, where he was placed in a supine position.
Left upper extremity was sterilely prepped and draped in the usual fashion.
Esmarch bandage was used to exsanguinate the left upper extremi: G56.02 Carpal
tunnel syndrome, left upper limb
29848 1 LT Ndsc Wrst Surg W/rls Transvrs Carpl
7. Emergency Department ReportSex: MAGE: 8DOB: 1/1/20xxDOS:
01/01/20XXTime Seen: 09:54Arrived- By private vehicle. Historian- mother.HIS-
TORY OF PRESENT ILLNESSChief Complaint- VOMITING. This started today and
is now gone. It was abrupt in onset. The symptoms are described as moderate.
He has had a subjective fever (- gone). The patient has had vomiting and
decreased oral intake. He has had abdominal pain (- gone). No diarrhea, bloody
stools, black stools, ank 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 �ne save for
decrease appetite.).Similar symptoms previously: He has had similar symptoms
once previously. These were milder. (Last week for one day.).Recent medical
, Practicode Set 1-200
Study online at https://quizlet.com/_etzafu
care: The patient was seen recently in: R11.10 Vomiting, unspeci�ed
99282 Emergency department visit for the e
8. OPERATIVE REPORTSEX: FEMALEAGE: 46DATE OF OPERATION: 1/1/20XXPRE-
OPERATIVE DIAGNOSIS: L2 WEDGE COMPRESSION FRACTURE.PROCEDURES:
L2 VERTEBROPLASTY.POSTOPERATIVE DIAGNOSIS: L2 WEDGE COMPRESSION
FRACTURE.SURGEON: Christian Jones, MDANESTHESIA: GENERAL.ESTIMATED
BLOOD LOSS: TWO TO THREE DROPS.COMPLICATIONS: NONE.INDICATIONS:
The patient is a middle-aged woman who several days prior su ered a fall
which she felt was a compression fracture of the L2 vertebral body. The patient
was neurologically un-compromised. She was complaining severe pain due
to the fracture and because of the presence of angulation in the fracture,
my recommendation was to perform a vertebroplasty. The procedure along
with its risks, possible bene�ts and possible complications were explained to
the patient to her understanding. Surgical and nonsurgical alternatives were
discussed with her and her questions were answered to her satisfaction. She
conse: S32.020A Wedge compression fracture of second
22511 1 Perq Vertebroplasty Uni/Bi Injection
9. EMERGENCY DEPARTMENTSEX: FemaleAGE: 97DOS: 1/1/20XXCHIEF COM-
PLAINT: Low blood pressure per Skyler sta .HISTORY OF PRESENT ILLNESS:
This is a female who was brought here from Skyler because she was thought
to have a low blood pressure and hypothermia. She herself has had no com-
plaints. She is in declining health, having been moved from her home to Skyler 3
weeks ago. She has had physical and mental deterioration over the past month
or so. She is in the process of being moved into the enhanced care unit at Skyler
and there was discussion about having hospice begin providing care for her.
The patient's son came to provide more information as the patient is not able to
answer questions with reliability.PAST MEDICAL HISTORY: Signi�cant for hyper-
tension, arthritis, anxiety, hypothyroidism, incontinence, frequent UTIs.MED-
ICATIONS:Valium.Aspirin.Potassium.Nexium.Diovan.Lasix.Armour Thyroid.AL-
LERGIES: KEFLEX AND TAPE.SOCIAL: R53.1 Weakness E86.0 Dehydration E87.1 Hypo-osmolality and
hyponatremia
99284 Emergency department visit for the e
Study online at https://quizlet.com/_etzafu
1. RADIOLOGY REPORT Location: AAPC Family Practice
Sex: MAGE: 31DATE OF EXAM: 1/01/20XXREFERRED BY PHYSICIAN(S): M.D.PRO-
CEDURE: X-RAY ABDOMEN/KUB SUPINE, ONE VIEWCOMPARISON: None.I NDI-
CATIONS: Abdomen pain. History of stones. TECHNIQUE: A single AP supine
view of the abdomen was performed. FINDINGS:BOWEL GAS PATTERN: Nor-
mal. CALCIFICATIONS: None signi�cant. OTHER: Normal for age. CONCLUSION:
1. NORMAL EXAM. NO KIDNEY STONES IDENTIFIED. Electronically signed by
1/1/20XX
Case ID : OPD7029: R10.9 Unspeci�ed abdominal pain
Z87.442 Personal history of urinary calculi
740181 Radiologic Exam Abdomen 1 View
2. OFFICE - ESTABLISHED Sex: FAGE 71Date: 01/01/20XXCHIEF CONCERN: She
is here for follow up of CPAP titration. PROBLEM LIST:1. A female with VVI
pacemaker replacement (20XX), for chronic atrial �brillation with intermittent
high grade A-V block and uncontrolled ventricular rate.2. Recurrent heart fail-
ure associated with atrial �brillation with rapid ventricular response.3. Recur-
rent deep venous thrombosis with a Green�eld vena cava �lter placed, on
maintenance Coumadin.4. Remote history of pulmonary embolism.5. Presyn-
copal 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 o ce visit, the pa: G47.30 Sleep apnea, unspeci�ed
R41.3 Other amnesia
Z79.01 Long term (current) use of anticoagu
99213 O ce/outpatient Established Low Md
3. OPERATIVE REPORTAGE: 39DOS: 1/1/20XXPHYSICIAN: Carrol Andrews, MD-
PREOPERATIVE DIAGNOSIS: Bilateral macromastia (hypertrophy).POSTOPER-
ATIVE DIAGNOSIS: Bilateral macromastia (hypertrophy).OPERATIVE PROCE-
DURE: Bilateral reduction mammoplasty. SURGEON: Carrol Andrews, MDANES-
, Practicode Set 1-200
Study online at https://quizlet.com/_etzafu
THESIA: 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 signi�cant macromastia where
I explained that this goal would be easily achieved. The patient agreed and
wished to proceed with surgery. DESCRIPTION OF PROCEDURE: The patient
was brought to the operating room where she was placed in supine position.
She was placed under general anesthesia. Bilateral upper extremities were
secured to arm boards with cast padding. Both breasts were marked in: N62
Hypertrophy of breast
193181 mod:50 Breast Reduction
4. OFFICE - ESTABLISHED SEX: FEMALEAGE: 69DOS: 1/1/20XXCHIEF COMPLAINT:
Bilateral back pain, muscle pain. HPI: Back Pain: Reported by Patient: Locations:
pain radiating to the buttocks; pain radiating to the legs. Quality: sharp. Severi-
ty: 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; exing back; extending back. Associ-
ated 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: Re-
viewed Medications: ADVAIR DISKUSATENOLOL 100 MG TABFENTANYLFLUTI-
CASONEHYDROCODONE 10 MG TABLY: E87.6 Hypokalemia
M51.36 Other intervertebral disc degenerative
99213 O ce/outpatient Established Low Md
5. OFFICE VISIT - EST Sex: MAGE: 44DOS: 1/1/20XXSUBJECTIVE: The patient is
a male being seen for lumbar back pain. The symptoms have been gradual
in onset with a severity of 6/10 in pain score. This lumbar back pain is also
associated with headaches. Both sides are a ected equally. He has had no
history of surgery .OBJECTIVE: On exam, he has di use lower lumbar back pain
and headache PLAN: The patient will need a lumbar AP and lateral plain �lm
, Practicode Set 1-200
Study online at https://quizlet.com/_etzafu
for further evaluation. Patient to return to o ce after obtaining further studies
or if symptoms get worse David Kramer, MD Electronically signed by DAVID
KRAMER, MD 1/1//20XX
Case ID : OPD7206: M54.50 Low back pain, unspeci�ed
R51.9 Headache, unspeci�ed
6. SEX: MALEAGE: 75DOS: 1/1/20XXPHYSICIAN: Sidney Jones, MDPREOPERA-
TIVE DIAGNOSIS: Left carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS:
Left carpal tunnel syndrome. OPERATIVE PROCEDURE: Left endoscopic carpal
tunnel release. SURGEON: Sidney Jones, MDANESTHESIA: General. COMPLI-
CATIONS: None. INDICATIONS: The patient a male who presented to clin-
ic with left hand paresthesias in the median nerve distribution. Symptoms
failed to improve with conservative management. Therefore, I recommended
left endoscopic carpal tunnel release. The patient agreed, understanding the
risks of nerve injury, tendon injury, persistent symptoms, recurrent symptoms,
and need for further surgery. DESCRIPTION OF PROCEDURE: The patient was
brought to the operating room, where he was placed in a supine position.
Left upper extremity was sterilely prepped and draped in the usual fashion.
Esmarch bandage was used to exsanguinate the left upper extremi: G56.02 Carpal
tunnel syndrome, left upper limb
29848 1 LT Ndsc Wrst Surg W/rls Transvrs Carpl
7. Emergency Department ReportSex: MAGE: 8DOB: 1/1/20xxDOS:
01/01/20XXTime Seen: 09:54Arrived- By private vehicle. Historian- mother.HIS-
TORY OF PRESENT ILLNESSChief Complaint- VOMITING. This started today and
is now gone. It was abrupt in onset. The symptoms are described as moderate.
He has had a subjective fever (- gone). The patient has had vomiting and
decreased oral intake. He has had abdominal pain (- gone). No diarrhea, bloody
stools, black stools, ank 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 �ne save for
decrease appetite.).Similar symptoms previously: He has had similar symptoms
once previously. These were milder. (Last week for one day.).Recent medical
, Practicode Set 1-200
Study online at https://quizlet.com/_etzafu
care: The patient was seen recently in: R11.10 Vomiting, unspeci�ed
99282 Emergency department visit for the e
8. OPERATIVE REPORTSEX: FEMALEAGE: 46DATE OF OPERATION: 1/1/20XXPRE-
OPERATIVE DIAGNOSIS: L2 WEDGE COMPRESSION FRACTURE.PROCEDURES:
L2 VERTEBROPLASTY.POSTOPERATIVE DIAGNOSIS: L2 WEDGE COMPRESSION
FRACTURE.SURGEON: Christian Jones, MDANESTHESIA: GENERAL.ESTIMATED
BLOOD LOSS: TWO TO THREE DROPS.COMPLICATIONS: NONE.INDICATIONS:
The patient is a middle-aged woman who several days prior su ered a fall
which she felt was a compression fracture of the L2 vertebral body. The patient
was neurologically un-compromised. She was complaining severe pain due
to the fracture and because of the presence of angulation in the fracture,
my recommendation was to perform a vertebroplasty. The procedure along
with its risks, possible bene�ts and possible complications were explained to
the patient to her understanding. Surgical and nonsurgical alternatives were
discussed with her and her questions were answered to her satisfaction. She
conse: S32.020A Wedge compression fracture of second
22511 1 Perq Vertebroplasty Uni/Bi Injection
9. EMERGENCY DEPARTMENTSEX: FemaleAGE: 97DOS: 1/1/20XXCHIEF COM-
PLAINT: Low blood pressure per Skyler sta .HISTORY OF PRESENT ILLNESS:
This is a female who was brought here from Skyler because she was thought
to have a low blood pressure and hypothermia. She herself has had no com-
plaints. She is in declining health, having been moved from her home to Skyler 3
weeks ago. She has had physical and mental deterioration over the past month
or so. She is in the process of being moved into the enhanced care unit at Skyler
and there was discussion about having hospice begin providing care for her.
The patient's son came to provide more information as the patient is not able to
answer questions with reliability.PAST MEDICAL HISTORY: Signi�cant for hyper-
tension, arthritis, anxiety, hypothyroidism, incontinence, frequent UTIs.MED-
ICATIONS:Valium.Aspirin.Potassium.Nexium.Diovan.Lasix.Armour Thyroid.AL-
LERGIES: KEFLEX AND TAPE.SOCIAL: R53.1 Weakness E86.0 Dehydration E87.1 Hypo-osmolality and
hyponatremia
99284 Emergency department visit for the e
