Chapter 4: Study Guide Practical
Application
CASE 1
PROGRESS NOTE
This patient is a 50-year-old female who began developing bleeding, bright red blood per
rectum (Patient's presenting complaint.), approximately two weeks ago. She is referred by her
family physician. She states that after a bowel movement she noticed blood in the toilet. She
denied any prior history of bleeding or pain with defecation. She states that she has had an
external hemorrhoid (This is reported by the patient, but not documented in the exam or
assessment, so it is not coded.) that did bleed at times but that is not where this bleeding is
coming from. She is presently concerned because a close friend of hers was recently diagnosed
with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is
here today for evaluation for a colonoscopy.
Physical examination, she appears to be a well appearing 50-year-old, white female. Abdomen is
soft, non-tender, non-distended. - Answer K62.5
CASE 2
PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.
POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.(Report the
postoperative diagnosis.)
PROCEDURES PERFORMED:
1. Placement of left Nucleus cochlear implant.
2. Facial nerve monitoring for an hour.
3. Microscope use.
ANESTHESIA: General.
INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis
is documented as the indication for the
surgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for
cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were
described to the patient, who voiced understanding and wished to proceed.
PROCEDURE: After properly identifying the patient, she was taken to the main operating room,
where general anesthetic was induced. The table was turned to 180 degrees and a standard left-
sided post - Answer H90.3
CASE 3
CC: HTN
INTERVAL HISTORY: No new complaints.
EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-tender.
No peripheral edema.
Application
CASE 1
PROGRESS NOTE
This patient is a 50-year-old female who began developing bleeding, bright red blood per
rectum (Patient's presenting complaint.), approximately two weeks ago. She is referred by her
family physician. She states that after a bowel movement she noticed blood in the toilet. She
denied any prior history of bleeding or pain with defecation. She states that she has had an
external hemorrhoid (This is reported by the patient, but not documented in the exam or
assessment, so it is not coded.) that did bleed at times but that is not where this bleeding is
coming from. She is presently concerned because a close friend of hers was recently diagnosed
with rectal carcinoma requiring chemotherapy that was missed by her primary doctor. She is
here today for evaluation for a colonoscopy.
Physical examination, she appears to be a well appearing 50-year-old, white female. Abdomen is
soft, non-tender, non-distended. - Answer K62.5
CASE 2
PREOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.
POSTOPERATIVE DIAGNOSIS: Bilateral profound sensorineural hearing loss.(Report the
postoperative diagnosis.)
PROCEDURES PERFORMED:
1. Placement of left Nucleus cochlear implant.
2. Facial nerve monitoring for an hour.
3. Microscope use.
ANESTHESIA: General.
INDICATIONS: This is a 69-year-old woman who has had progressive hearing loss (The diagnosis
is documented as the indication for the
surgery.) over the last 10-15 years. Hearing aids are not useful for her. She is a candidate for
cochlear implant by FDA standards. The risks, benefits, and alternatives of procedure were
described to the patient, who voiced understanding and wished to proceed.
PROCEDURE: After properly identifying the patient, she was taken to the main operating room,
where general anesthetic was induced. The table was turned to 180 degrees and a standard left-
sided post - Answer H90.3
CASE 3
CC: HTN
INTERVAL HISTORY: No new complaints.
EXAM: NAD. 130/80, 84, 22. Lungs are clear. Heart RRR, no MRGs. Abdomen is soft, non-tender.
No peripheral edema.
