Practicode: Cases Part 2 Test
Questions All Answered Correctly
2025-2026 Updated.
OPD6941 Case Year Version: 2024
Primary Diagnosis: M84.48XA
CPT: 22513-53 - Answer OPD6941 MEDICAL RECORD
Age: 82 Sex: FEMALE Date of Service: 1/1/20XX Service Department: Orthopedic Group General
Provider: Dr. OPERATIVE NOTE: PREOPERATIVE DIAGNOSIS: Pathological fracture approximately
T-5. Possible Malignant neoplasm of vertebral column. POSTOPERATIVE DIAGNOSIS: Same
NAME OF PROCEDURE: Percutaneous vertebral augmentation with cavity creation, mechanical
device one vertebral body, thoracic. SURGEON: ANESTHESIA: GENERAL ESTIMATED BLOOD LOSS:
Negligible. COMPLICATIONS: None INDICATIONS: Severe thoracic spine pain just above the bra
strap. Radiates to the left ribs. IMAGING STUDIES: Pathological fracture above T-5. MRI SCAN:
Deferred. The patient could not tolerate the machine. CAT SCAN: Deferred. The patient could
not tolerate the machine. BONE SCAN: Very hot at T-5. Has multiple hot areas in the spine,
including multiple areas of spine, T-5, multiple rib spots, left sacral ala, right and left femurs,
shoulders. Pattern highly suspicious for metastatic disease. X-RAYS: T-5 pathological fracture.
Alkaline phosphatase elevated PLAN: Kyphoplasty, biopsy DESCRIPTION OF PROCEDURE: Guide
wire introduced, trying this on the left side. We spent about ten minutes trying to get it into the
correct position on the left side and just could not get it into good position. I therefore elected
not to do this on the left side. On the right side the patient was rotated and shooting straight
down the pedicle. Again, infiltration on this plan, the guide wire was able to get into the right
side and into vertebral body. This was followed with cannulated drill bit, then the working
channel and then the articulating curette to create a cavity. Very gently insertion the balloon.
With balloon inserted, I tried to fill it and was worried it was going to fracture to the end-plate. I
elected just to do a small amount of filling. O
OPD6940 Case Year Version: 2024
Primary Diagnosis: M16.11
CPT: 27130-RT - Answer OPD6940 MEDICAL RECORD
Age: 81 SEX: MALE Date of Service: 1/1/20XX Service Department: Orthopedic Group General
PREOPERATIVE DIAGNOSIS: Severe Primary osteoarthritis of the right hip. POSTOPERATIVE
DIAGNOSIS: Severe Primary osteoarthritis of the right hip. NAME OF PROCEDURE: Right AML
press-fit metal on metal total hip arthroplasty. SURGEON: ASSISTANT: DESCRIPTION OF
PROCEDURE: The patient was given 2 grams of Ancef IV, a spinal anesthetic, then a general
anesthetic for the procedure. Foley catheter was placed in the bladder. The patient was placed
in the left lateral position where his right hip and lower extremity were prepped and draped in
the usual sterile fashion. Space suits were used. A straight lateral approach was made and
carefully carried down to the fascia lata, which was split, bleeders were cauterized, a Charnley
retractor was placed. The anterior one-half of the gluteus medius and minimus free from the
greater trochanter, capsule was opened anterolaterally in a T-shaped fashion. The hip was
,dislocated and the neck was sectioned. Appropriate level for the AML component, the
acetabular labrum was excised, irrigated with PB solution and deepened and reamed to a 52
outside diameter. The wound was thoroughly irrigated with PB solution. The spike pore-coated
52 outside diameter AML cup was impacted in 15 degrees of anteversion. A hole eliminator was
applied. The wound was irrigated with PB solution. A 36 inside diameter metal on metal
component was impacted. Attention was turned to the proximal femur, which was prepared
with reamers and broaches to accept the standard 10.5. The wound was again irrigated with PB
solution and the standard 10.5 fully coated prosthesis was impacted in neutral position. Trial
reduction proved a +12 gave excellent stability and leg length, therefore, the +12, 36 headed
component was
OPD6938 Case Year Version: 2022
Primary Diagnosis: M94.261
Secondary Diagnosis: M67.51
CPT: 29875-RT - Answer OPD6938 MEDICAL RECORD
Age: 57 SEX: FEMALE Date of Service: 1/1/20XX Service Department: Orthopedic Group General
Provider: OPERATIVE DIAGNOSIS: Right knee symptomatic medial plica, with medial femoral
condyle chondromalacia. NAME OF PROCEDURE: Right knee examination under anesthesia,
arthroscopy, medial plica excision, and medial femoral condyle chondroplasty. SURGEON:
ASSISTANT: ANESTHESIA: General DESCRIPTION OF PROCEDURE: With the patient in the supine
position under endotracheal intubation with general anesthesia, the right knee was examined.
She had full range of motion, with all ligaments stable. No effusion. Portals were preinjected.
The knee was prepped and draped free in the usual manner. Portals were established
inferolaterally and inferomedially. In the medial compartment, we identified normal cartilage on
both articular surfaces. Careful visualization and probing of the medial meniscus, both superior
and inferior surfaces, failed to reveal any sort of tearing. In the notch, the anterior and posterior
cruciate ligaments were intact to visualization and probing. We did notice, however, that there
was a large medial plica present. In the lateral compartment, we found intact cartilage on both
articular surfaces. The lateral meniscus, popliteal tendon, and hiatus were all intact to
visualization and probing. In the patellofemoral joint, we had normal alignment. Both the right
patellar surface and femoral trochlea were intact. However, in the medial gutter, we noted a
very large plica. There was tissue pinching between the patella and femur, and there was
chondromalacia over the edge of the femur. Therefore, we felt that the meniscal tears that we
suspected were not present and that this plica could explain her symptoms. We therefore went
ahead with excision of the plica and a chondroplasty. We irrigated with st
OPD6998 Case Year Version: 2022
Primary Diagnosis: K80.50
CPT: 47562 - Answer OPD6998 MEDICAL RECORD
OPERATIVE NOTE AGE: 35 SEX: Male DOS: 1/1/20XX PHYSICIAN: MD PREOPERATIVE DIAGNOSIS:
Biliary colic. POSTOPERATIVE DIAGNOSIS: Biliary colic. OPERATIVE PROCEDURE: Laparoscopic
cholecystectomy. SURGEON: MD ANESTHESIA: 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 con
OPD6982 Case Year Version: 2024
Primary Diagnosis: A63.0
Secondary Diagnosis: Z21
CPT: 46612 - Answer OPD6982 MEDICAL RECORD
AGE: 53 SEX: MALE DATE OF OPERATION:1/1/20XX PREOPERATIVE DIAGNOSIS: ANAL
CONDYLOMATAS PROCEDURES: FULGURATION OF ANAL CONDYLOMATAS - ANOSCOPY
POSTOPERATIVE DIAGNOSIS: ANAL CONDYLOMATAS SURGEON: MD Conscious 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
OPD6971 Case Year Version: 2024
Primary Diagnosis: I74.2
CPT: 34101-RT - Answer OPD6971 MEDICAL RECORD
, OPERATIVE REPORT AGE: 44 Y SEX: FEMALE DATE OF OPERATION: 01/01/20XX PREOPERATIVE
DIAGNOSIS: RIGHT UPPER EXTREMITY PROCEDURES: 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
OPD6958 Case Year Version: 2024
Primary Diagnosis: S42.022A
Secondary Diagnosis: V29.99XA
CPT: 23515-LT
According to ICD-10-CM Guidelines, when a fracture is not specified as open or closed it is
reported as closed. According to ICD-10-CM Guidelines, when a fracture is not specified as
displaced or nondisplaced it is reported as displaced. The diagnosis is a midshaft clavicle
fracture due to an accident. Look in the ICD-10-CM Alphabetic Index for Fracture,
traumatic/clavicle/shaft which refers you to S42.02-. Verify code selection in the Tabular List,
this code requires a 6th and 7th character. The 6th character is for which side, and the 7th
character is A for active treatment.
Look in the Index to External Causes of Injuries, Accident/motorcycle NOS - see Accident,
transport, motorcycle which refers you to V29.99. This code requires a 7th character. Verify the
code selection in the Tabular List. - Answer OPD6958 MEDICAL RECORD
Questions All Answered Correctly
2025-2026 Updated.
OPD6941 Case Year Version: 2024
Primary Diagnosis: M84.48XA
CPT: 22513-53 - Answer OPD6941 MEDICAL RECORD
Age: 82 Sex: FEMALE Date of Service: 1/1/20XX Service Department: Orthopedic Group General
Provider: Dr. OPERATIVE NOTE: PREOPERATIVE DIAGNOSIS: Pathological fracture approximately
T-5. Possible Malignant neoplasm of vertebral column. POSTOPERATIVE DIAGNOSIS: Same
NAME OF PROCEDURE: Percutaneous vertebral augmentation with cavity creation, mechanical
device one vertebral body, thoracic. SURGEON: ANESTHESIA: GENERAL ESTIMATED BLOOD LOSS:
Negligible. COMPLICATIONS: None INDICATIONS: Severe thoracic spine pain just above the bra
strap. Radiates to the left ribs. IMAGING STUDIES: Pathological fracture above T-5. MRI SCAN:
Deferred. The patient could not tolerate the machine. CAT SCAN: Deferred. The patient could
not tolerate the machine. BONE SCAN: Very hot at T-5. Has multiple hot areas in the spine,
including multiple areas of spine, T-5, multiple rib spots, left sacral ala, right and left femurs,
shoulders. Pattern highly suspicious for metastatic disease. X-RAYS: T-5 pathological fracture.
Alkaline phosphatase elevated PLAN: Kyphoplasty, biopsy DESCRIPTION OF PROCEDURE: Guide
wire introduced, trying this on the left side. We spent about ten minutes trying to get it into the
correct position on the left side and just could not get it into good position. I therefore elected
not to do this on the left side. On the right side the patient was rotated and shooting straight
down the pedicle. Again, infiltration on this plan, the guide wire was able to get into the right
side and into vertebral body. This was followed with cannulated drill bit, then the working
channel and then the articulating curette to create a cavity. Very gently insertion the balloon.
With balloon inserted, I tried to fill it and was worried it was going to fracture to the end-plate. I
elected just to do a small amount of filling. O
OPD6940 Case Year Version: 2024
Primary Diagnosis: M16.11
CPT: 27130-RT - Answer OPD6940 MEDICAL RECORD
Age: 81 SEX: MALE Date of Service: 1/1/20XX Service Department: Orthopedic Group General
PREOPERATIVE DIAGNOSIS: Severe Primary osteoarthritis of the right hip. POSTOPERATIVE
DIAGNOSIS: Severe Primary osteoarthritis of the right hip. NAME OF PROCEDURE: Right AML
press-fit metal on metal total hip arthroplasty. SURGEON: ASSISTANT: DESCRIPTION OF
PROCEDURE: The patient was given 2 grams of Ancef IV, a spinal anesthetic, then a general
anesthetic for the procedure. Foley catheter was placed in the bladder. The patient was placed
in the left lateral position where his right hip and lower extremity were prepped and draped in
the usual sterile fashion. Space suits were used. A straight lateral approach was made and
carefully carried down to the fascia lata, which was split, bleeders were cauterized, a Charnley
retractor was placed. The anterior one-half of the gluteus medius and minimus free from the
greater trochanter, capsule was opened anterolaterally in a T-shaped fashion. The hip was
,dislocated and the neck was sectioned. Appropriate level for the AML component, the
acetabular labrum was excised, irrigated with PB solution and deepened and reamed to a 52
outside diameter. The wound was thoroughly irrigated with PB solution. The spike pore-coated
52 outside diameter AML cup was impacted in 15 degrees of anteversion. A hole eliminator was
applied. The wound was irrigated with PB solution. A 36 inside diameter metal on metal
component was impacted. Attention was turned to the proximal femur, which was prepared
with reamers and broaches to accept the standard 10.5. The wound was again irrigated with PB
solution and the standard 10.5 fully coated prosthesis was impacted in neutral position. Trial
reduction proved a +12 gave excellent stability and leg length, therefore, the +12, 36 headed
component was
OPD6938 Case Year Version: 2022
Primary Diagnosis: M94.261
Secondary Diagnosis: M67.51
CPT: 29875-RT - Answer OPD6938 MEDICAL RECORD
Age: 57 SEX: FEMALE Date of Service: 1/1/20XX Service Department: Orthopedic Group General
Provider: OPERATIVE DIAGNOSIS: Right knee symptomatic medial plica, with medial femoral
condyle chondromalacia. NAME OF PROCEDURE: Right knee examination under anesthesia,
arthroscopy, medial plica excision, and medial femoral condyle chondroplasty. SURGEON:
ASSISTANT: ANESTHESIA: General DESCRIPTION OF PROCEDURE: With the patient in the supine
position under endotracheal intubation with general anesthesia, the right knee was examined.
She had full range of motion, with all ligaments stable. No effusion. Portals were preinjected.
The knee was prepped and draped free in the usual manner. Portals were established
inferolaterally and inferomedially. In the medial compartment, we identified normal cartilage on
both articular surfaces. Careful visualization and probing of the medial meniscus, both superior
and inferior surfaces, failed to reveal any sort of tearing. In the notch, the anterior and posterior
cruciate ligaments were intact to visualization and probing. We did notice, however, that there
was a large medial plica present. In the lateral compartment, we found intact cartilage on both
articular surfaces. The lateral meniscus, popliteal tendon, and hiatus were all intact to
visualization and probing. In the patellofemoral joint, we had normal alignment. Both the right
patellar surface and femoral trochlea were intact. However, in the medial gutter, we noted a
very large plica. There was tissue pinching between the patella and femur, and there was
chondromalacia over the edge of the femur. Therefore, we felt that the meniscal tears that we
suspected were not present and that this plica could explain her symptoms. We therefore went
ahead with excision of the plica and a chondroplasty. We irrigated with st
OPD6998 Case Year Version: 2022
Primary Diagnosis: K80.50
CPT: 47562 - Answer OPD6998 MEDICAL RECORD
OPERATIVE NOTE AGE: 35 SEX: Male DOS: 1/1/20XX PHYSICIAN: MD PREOPERATIVE DIAGNOSIS:
Biliary colic. POSTOPERATIVE DIAGNOSIS: Biliary colic. OPERATIVE PROCEDURE: Laparoscopic
cholecystectomy. SURGEON: MD ANESTHESIA: 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 con
OPD6982 Case Year Version: 2024
Primary Diagnosis: A63.0
Secondary Diagnosis: Z21
CPT: 46612 - Answer OPD6982 MEDICAL RECORD
AGE: 53 SEX: MALE DATE OF OPERATION:1/1/20XX PREOPERATIVE DIAGNOSIS: ANAL
CONDYLOMATAS PROCEDURES: FULGURATION OF ANAL CONDYLOMATAS - ANOSCOPY
POSTOPERATIVE DIAGNOSIS: ANAL CONDYLOMATAS SURGEON: MD Conscious 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
OPD6971 Case Year Version: 2024
Primary Diagnosis: I74.2
CPT: 34101-RT - Answer OPD6971 MEDICAL RECORD
, OPERATIVE REPORT AGE: 44 Y SEX: FEMALE DATE OF OPERATION: 01/01/20XX PREOPERATIVE
DIAGNOSIS: RIGHT UPPER EXTREMITY PROCEDURES: 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
OPD6958 Case Year Version: 2024
Primary Diagnosis: S42.022A
Secondary Diagnosis: V29.99XA
CPT: 23515-LT
According to ICD-10-CM Guidelines, when a fracture is not specified as open or closed it is
reported as closed. According to ICD-10-CM Guidelines, when a fracture is not specified as
displaced or nondisplaced it is reported as displaced. The diagnosis is a midshaft clavicle
fracture due to an accident. Look in the ICD-10-CM Alphabetic Index for Fracture,
traumatic/clavicle/shaft which refers you to S42.02-. Verify code selection in the Tabular List,
this code requires a 6th and 7th character. The 6th character is for which side, and the 7th
character is A for active treatment.
Look in the Index to External Causes of Injuries, Accident/motorcycle NOS - see Accident,
transport, motorcycle which refers you to V29.99. This code requires a 7th character. Verify the
code selection in the Tabular List. - Answer OPD6958 MEDICAL RECORD
