Practicode Cases Part 1 Questions | 2026/2027 | Answers
Correct | With Complete Solutions
OPD7381 Case Year Version: 2022
Primary Diagnosis: D25.1
Secondary Diagnosis: D50.0
CPT: 58140
OPD7381 MEDICAL RECORD
AGE: 36 SEX: FEMALE DATE OF OPERATION: 06/30/xx
PREOPERATIVE DIAGNOSIS: A 36-YEAR-OLD P-0 WITH
LARGE FIBROID UTERUS, SEVERE ANEMIA WITH
BLOOD LOSS, PELVIC PAIN, ABDOMINAL
MYOMECTOMY AND POSSIBLE LEFT SALPINGO-
OOPHORECTOMY. PROCEDURES: POSTOPERATIVE
DIAGNOSIS: ABDOMINAL MYOMECTOMY, EXAM
UNDER ANESTHESIA AND EXPLORATORY
LAPAROTOMY SURGEON: Luther Kramer, M.D. FIRST
ASSISTANT: ANESTHESIA: GENERAL,
ENDOTRACHEAL. ESTIMATED BLOOD LOSS: 300 CC. IV
FLUIDS: 2500 CC LACTATED RINGER'S. URINE OUTPUT:
300 CC OF CLEAR URINE AT THE END OF THE
PROCEDURE. COMPLICATIONS: NONE. FINDINGS:
Uterus enlarged 16 to 18 weeks in size, mobile and nontender.
Endometrial biopsy attempted but was not successful secondary
to the myoma obstructing the os. Intraop findings 16 weeks
uterus with large solitary myoma approximately 7 x 7 cm,
,intramural, removed without complications. Pitressin used for
hemostasis. Upon incision of the anterior uterine wall to remove
the fibroid, endometrial cavity was entered. Normal ovaries,
tubes and fimbria. INDICATIONS: The risks, benefits,
indications and alternatives of the procedure were discussed and
reviewed with the patient and informed consent was obtained,
signed and in chart. PROCEDURE: The patient was taken to the
operating room with IV running and Foley catheter to be placed.
The patient was placed in supine position, given general
anesthesia and prepped and draped in sterile fashion. A Foley
catheter was inserted. The endometrial biopsy was attempted but
was unsuccessful secondary to myoma obstructing the os. It was
not successful even with dilatation of the uterus. So the
procedure was abandoned and we proceeded with abdominal
myomectomy. The patient was prepped and draped in sterile
fashion. A vertical skin incision was made from approximately
symphysis pubis to 2 cm below the umbil
OPD7387 Case Year Version: 2022
Primary Diagnosis: N95.0
CPT: 58558
OPD7387 MEDICAL RECORD
OPERATIVE REPORT SEX: FEMALE AGE: 54 DATE OF
OPERATION: 11/21/20xx HOSPITAL/MR NUMBER:
1234567 SURGEON: Dr. O.B. Andrews. PREOPERATIVE
DIAGNOSES: Postmenopausal bleeding POSTOPERATIVE
DIAGNOSES: Postmenopausal bleeding PROCEDURES
PERFORMED: 1. Hysteroscopy 2. Dilation and Curettage
,ESTIMATED BLOOD LOSS: Minimal ANESTHESIA:
General COMPLICATIONS: None SPECIMENS: Endometrial
Curettings INDICATIONS FOR PROCEDURE: The patient is
54-year-old gravida 7 para 3 who presents complaining of
uterine bleeding. The patient states that it has been gradually
getting worse over the last 2 years. She states that she bleeds for
2 weeks at a time. She states in the post she has been told that
she had fibroids. She also had a uterine ablation 4 years ago. She
states this bleeding has been interfering with her otherwise
active lifestyle. FINDINGS: Mainly atrophic appearing
endometrium although there was a lot of stranding along the
endometrial lining most likely consistent with her ablation.
DESCRIPTION OF PROCEDURE: The patient was taken to the
operating room where general anesthesia was obtained without
difficulty. She was then positioned in dorsal lithotomy position
using Allen stirrups and prepped and draped in the usual sterile
fashion. A Graves speculum was placed in the introitus for
visualization of the cervix. A single toothed tenaculum was
attached to the posterior lip of the cervix. The cervix was
progressively dilated to #17 Hanks dilator. The hysteroscope
was then advanced under saline distention with finding as noted
above. The hysteroscope was then removed. The uterus was
gently sharp curetted in a 360-degree fashion. Small amount of
tissue was obtained which was submitted to pathology for
further evaluation. All instruments were removed. Complete
hemostasis was visualized. The patient was then awakene
OPD7402 Case Year Version: 2022
, Primary Diagnosis: Z12.31
CPT: 77067
OPD7402 MEDICAL RECORD
Study performed at Valley Radiology Center (Global Billing)
SEX: FEMALE Age: 67 DATE OF EXAM: 1/1/20XX
PHYSICIAN(S): Donald Kramer, M.D. PROCEDURE:
DIGITAL BILATERAL SCREENING MAMMOGRAM WITH
C.A.D. COMPARISON: 01/1/20XX INDICATIONS: Screening
mammogram. FINDINGS: There are scattered fibroglandular
densities that could obscure a lesion on mammography. No
suspicious masses, significant calcifications, or other findings
are seen. There is a biopsy scar on the left and this is stable.
There are scattered, numerous microcalcifications, but these are
all benign. Images were further evaluated with Computer Aided
Detection. CONCLUSION: There is no change since the
previous mammograms. There is no mammographic evidence of
malignancy. BI-RADS: CATEGORY 2: Benign finding.
RECOMMEND: The American Cancer Society and other
organizations recommend annual screening mammography
beginning at age 40. Casey Andrews, M.D. Electronically signed
by CASEY ANDREWS, MD 1/1/20XX
OPD7408 Case Year Version: 2024
Primary Diagnosis: M25.511
Secondary Diagnosis: M79.89, L53.9
E/M Level: 99283
Correct | With Complete Solutions
OPD7381 Case Year Version: 2022
Primary Diagnosis: D25.1
Secondary Diagnosis: D50.0
CPT: 58140
OPD7381 MEDICAL RECORD
AGE: 36 SEX: FEMALE DATE OF OPERATION: 06/30/xx
PREOPERATIVE DIAGNOSIS: A 36-YEAR-OLD P-0 WITH
LARGE FIBROID UTERUS, SEVERE ANEMIA WITH
BLOOD LOSS, PELVIC PAIN, ABDOMINAL
MYOMECTOMY AND POSSIBLE LEFT SALPINGO-
OOPHORECTOMY. PROCEDURES: POSTOPERATIVE
DIAGNOSIS: ABDOMINAL MYOMECTOMY, EXAM
UNDER ANESTHESIA AND EXPLORATORY
LAPAROTOMY SURGEON: Luther Kramer, M.D. FIRST
ASSISTANT: ANESTHESIA: GENERAL,
ENDOTRACHEAL. ESTIMATED BLOOD LOSS: 300 CC. IV
FLUIDS: 2500 CC LACTATED RINGER'S. URINE OUTPUT:
300 CC OF CLEAR URINE AT THE END OF THE
PROCEDURE. COMPLICATIONS: NONE. FINDINGS:
Uterus enlarged 16 to 18 weeks in size, mobile and nontender.
Endometrial biopsy attempted but was not successful secondary
to the myoma obstructing the os. Intraop findings 16 weeks
uterus with large solitary myoma approximately 7 x 7 cm,
,intramural, removed without complications. Pitressin used for
hemostasis. Upon incision of the anterior uterine wall to remove
the fibroid, endometrial cavity was entered. Normal ovaries,
tubes and fimbria. INDICATIONS: The risks, benefits,
indications and alternatives of the procedure were discussed and
reviewed with the patient and informed consent was obtained,
signed and in chart. PROCEDURE: The patient was taken to the
operating room with IV running and Foley catheter to be placed.
The patient was placed in supine position, given general
anesthesia and prepped and draped in sterile fashion. A Foley
catheter was inserted. The endometrial biopsy was attempted but
was unsuccessful secondary to myoma obstructing the os. It was
not successful even with dilatation of the uterus. So the
procedure was abandoned and we proceeded with abdominal
myomectomy. The patient was prepped and draped in sterile
fashion. A vertical skin incision was made from approximately
symphysis pubis to 2 cm below the umbil
OPD7387 Case Year Version: 2022
Primary Diagnosis: N95.0
CPT: 58558
OPD7387 MEDICAL RECORD
OPERATIVE REPORT SEX: FEMALE AGE: 54 DATE OF
OPERATION: 11/21/20xx HOSPITAL/MR NUMBER:
1234567 SURGEON: Dr. O.B. Andrews. PREOPERATIVE
DIAGNOSES: Postmenopausal bleeding POSTOPERATIVE
DIAGNOSES: Postmenopausal bleeding PROCEDURES
PERFORMED: 1. Hysteroscopy 2. Dilation and Curettage
,ESTIMATED BLOOD LOSS: Minimal ANESTHESIA:
General COMPLICATIONS: None SPECIMENS: Endometrial
Curettings INDICATIONS FOR PROCEDURE: The patient is
54-year-old gravida 7 para 3 who presents complaining of
uterine bleeding. The patient states that it has been gradually
getting worse over the last 2 years. She states that she bleeds for
2 weeks at a time. She states in the post she has been told that
she had fibroids. She also had a uterine ablation 4 years ago. She
states this bleeding has been interfering with her otherwise
active lifestyle. FINDINGS: Mainly atrophic appearing
endometrium although there was a lot of stranding along the
endometrial lining most likely consistent with her ablation.
DESCRIPTION OF PROCEDURE: The patient was taken to the
operating room where general anesthesia was obtained without
difficulty. She was then positioned in dorsal lithotomy position
using Allen stirrups and prepped and draped in the usual sterile
fashion. A Graves speculum was placed in the introitus for
visualization of the cervix. A single toothed tenaculum was
attached to the posterior lip of the cervix. The cervix was
progressively dilated to #17 Hanks dilator. The hysteroscope
was then advanced under saline distention with finding as noted
above. The hysteroscope was then removed. The uterus was
gently sharp curetted in a 360-degree fashion. Small amount of
tissue was obtained which was submitted to pathology for
further evaluation. All instruments were removed. Complete
hemostasis was visualized. The patient was then awakene
OPD7402 Case Year Version: 2022
, Primary Diagnosis: Z12.31
CPT: 77067
OPD7402 MEDICAL RECORD
Study performed at Valley Radiology Center (Global Billing)
SEX: FEMALE Age: 67 DATE OF EXAM: 1/1/20XX
PHYSICIAN(S): Donald Kramer, M.D. PROCEDURE:
DIGITAL BILATERAL SCREENING MAMMOGRAM WITH
C.A.D. COMPARISON: 01/1/20XX INDICATIONS: Screening
mammogram. FINDINGS: There are scattered fibroglandular
densities that could obscure a lesion on mammography. No
suspicious masses, significant calcifications, or other findings
are seen. There is a biopsy scar on the left and this is stable.
There are scattered, numerous microcalcifications, but these are
all benign. Images were further evaluated with Computer Aided
Detection. CONCLUSION: There is no change since the
previous mammograms. There is no mammographic evidence of
malignancy. BI-RADS: CATEGORY 2: Benign finding.
RECOMMEND: The American Cancer Society and other
organizations recommend annual screening mammography
beginning at age 40. Casey Andrews, M.D. Electronically signed
by CASEY ANDREWS, MD 1/1/20XX
OPD7408 Case Year Version: 2024
Primary Diagnosis: M25.511
Secondary Diagnosis: M79.89, L53.9
E/M Level: 99283
