HI 255 MC2 Unit 8 Lab Assignment 3 | Latest 2025/2026 Update with complete solutions –
PGU.
Unit 8 Lab Assignment 3
ESTABLISHED PATIENT
HISTORY OF PRESENT ILLNESS: The patient is a 7-year-old boy who
presents today with his mother due to jamming his finger in the door this
morning. He caught his right middle finger in the door leading to his garage.
It occurred about 40 minutes prior to his arrival at the clinic. We last saw him
6 weeks ago for his annual physical.
PHYSICAL EXAMINATION: Temperature 98.4, pulse 79, respirations 14,
blood pressure 90/60. Heart has a regular rate and rhythm. Lungs are clear
to auscultation. Abdomen is soft. The patient is alert and resting on his back
on the examination table. Examination of the right middle finger shows some
swelling and a flap of skin to the distal right middle finger that is raised.
There appears to be no involvement of the nail bed itself, no subungual
hematoma present. Distal extremity is neurovascularly intact.
RADIOGRAPHS: X-rays done on the right middle finger done at the imaging
center do not demonstrate any fracture to the distal tip. Await official report
of radiology.
PROCEDURE: The patient was taken to the procedure room. Informed
consent was obtained from the patient’s mother, and she gave permission
for laceration repair. He was placed in a supine position, and a digital block
was performed with 2 mL of 2% lidocaine. The area was then cleansed and
irrigated with copious amounts of sterile saline. The area was then draped in
a sterile fashion and three 5-0 Ethilon interrupted sutures were placed to
realign the 1-cm flap. Dressing was applied and patient tolerated it well.
ASSESSMENT: Laceration of the right middle finger
PLAN:
1. Status post repair.
2. Wound care directions were given. The patient will follow up in 7 to 10
days for suture removal or sooner if any condition worsens or problems arise.
, HISTORY: Medically appropriate
EXAMINATION: Medically appropriate
MEDICAL DECISION MAKING: Low
CAC Results:
S61.21 Laceration without foreign body of right middle finger without
2A damage to nail, initial encounter
99202 Office and outpatient E/M, new, straightforward complexity
12011 Wound repair, finger, 1.0 cm
S61.212A Laceration without foreign body of right middle finger
without damage to nail, initial encounter (CAC was correct)
99213 Office and outpatient E/M, established, low complexity (Note the first
line of the case which specified Established Patient)
12001 Wound repair, finger, 1.0 cm
DATE OF PROCEDURE: 03/07/20XX
HISTORY: This is a 59-year-old man with metastatic lung cancer who
presented for EEG in the office with a diagnosis of status epilepticus on
March 3, 20XX.
CONDITIONS: This is an 18-channel EEG done using the 10–20 system
electrode placement. During the study, the patient was not able to follow
commands and at times he groaned and yawned throughout this
examination.
FINDINGS: The EEG begins with the patient’s eyes closed and there is a
posterior dominant rhythm of 7 on the left and 7 on the right. Photic
stimulation and hyperventilation were not done. Sleep was not obtained.
There was some left temporal slowing shown in leads T5-01 and FP1-F3.
There was no epileptiform activity seen.
PGU.
Unit 8 Lab Assignment 3
ESTABLISHED PATIENT
HISTORY OF PRESENT ILLNESS: The patient is a 7-year-old boy who
presents today with his mother due to jamming his finger in the door this
morning. He caught his right middle finger in the door leading to his garage.
It occurred about 40 minutes prior to his arrival at the clinic. We last saw him
6 weeks ago for his annual physical.
PHYSICAL EXAMINATION: Temperature 98.4, pulse 79, respirations 14,
blood pressure 90/60. Heart has a regular rate and rhythm. Lungs are clear
to auscultation. Abdomen is soft. The patient is alert and resting on his back
on the examination table. Examination of the right middle finger shows some
swelling and a flap of skin to the distal right middle finger that is raised.
There appears to be no involvement of the nail bed itself, no subungual
hematoma present. Distal extremity is neurovascularly intact.
RADIOGRAPHS: X-rays done on the right middle finger done at the imaging
center do not demonstrate any fracture to the distal tip. Await official report
of radiology.
PROCEDURE: The patient was taken to the procedure room. Informed
consent was obtained from the patient’s mother, and she gave permission
for laceration repair. He was placed in a supine position, and a digital block
was performed with 2 mL of 2% lidocaine. The area was then cleansed and
irrigated with copious amounts of sterile saline. The area was then draped in
a sterile fashion and three 5-0 Ethilon interrupted sutures were placed to
realign the 1-cm flap. Dressing was applied and patient tolerated it well.
ASSESSMENT: Laceration of the right middle finger
PLAN:
1. Status post repair.
2. Wound care directions were given. The patient will follow up in 7 to 10
days for suture removal or sooner if any condition worsens or problems arise.
, HISTORY: Medically appropriate
EXAMINATION: Medically appropriate
MEDICAL DECISION MAKING: Low
CAC Results:
S61.21 Laceration without foreign body of right middle finger without
2A damage to nail, initial encounter
99202 Office and outpatient E/M, new, straightforward complexity
12011 Wound repair, finger, 1.0 cm
S61.212A Laceration without foreign body of right middle finger
without damage to nail, initial encounter (CAC was correct)
99213 Office and outpatient E/M, established, low complexity (Note the first
line of the case which specified Established Patient)
12001 Wound repair, finger, 1.0 cm
DATE OF PROCEDURE: 03/07/20XX
HISTORY: This is a 59-year-old man with metastatic lung cancer who
presented for EEG in the office with a diagnosis of status epilepticus on
March 3, 20XX.
CONDITIONS: This is an 18-channel EEG done using the 10–20 system
electrode placement. During the study, the patient was not able to follow
commands and at times he groaned and yawned throughout this
examination.
FINDINGS: The EEG begins with the patient’s eyes closed and there is a
posterior dominant rhythm of 7 on the left and 7 on the right. Photic
stimulation and hyperventilation were not done. Sleep was not obtained.
There was some left temporal slowing shown in leads T5-01 and FP1-F3.
There was no epileptiform activity seen.
