BUSN 2370 Final Exam study guide

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Central Georgia Technical College *

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2370

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Medicine

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Jan 9, 2024

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During Mrs. Smith's visit to Dr. Johnson she provides a description of a concerning health condition.. Mrs. Smith believes that Dr. Johnson will use this information to evaluate and manage her condition and for no other purpose. Mrs. Smith's belief is an expectation of ____. confidentiality The documentation type that contains various types of analyses or examinations of body substances collected from the patient. Lab Report Vital statistics for live births that are sent to a healthcare database are an example of _____. secondary data Which of the following is NOT a benefit of switching from a paper-based record to an electronic-based record? Coding accuracy A portal through which patients can view and manage their healthcare information online is called a(n)_____ this information is owned and managed by ______. personal health record; the patient Which of the following is an ancillary report? Radiology Which of the following is true in regard to the release of protected health information (ROI)? A covered entity must provide access to PHI in the manner requested by the individual Healthcare Delivery Systems After suffering a stroke, a patient requires therapy to assist in performing activities of daily living such as getting dressed and cooking. Which department would assist this patient? Occupational therapy Which federal agency is tasked with governing and regulating healthcare in the United States? Department of Health and Human Services (DHHS) Dr. Taylor wants to join the medical staff at ABC hospital. Which of the following would the medical administration office check to see if Dr. Taylor meets the qualifications for hospital privileges? Medical staff bylaws Which of the following is another name for outpatient care? Ambulatory care The video player is currently playing an ad.

Which of the follow departments/specialties uses radioactive substances to diagnose and treat patients? Nuclear Medicine and Radiation Therapy Mrs.Thomas is discharged from the hospital but she will continue with IV antibiotics for 2 weeks. Which type of care would manage the administration of her antibiotics? Home Care Mr. Thomas has moved to a new city and is looking for a physician to help manage his diabetes. Which type of specialist would he look for? Endo Legal And Compliance Which of the following should NOT be included in a tracking system for disclosures of PHI? Social security numbers and diagnosis codes for the patient Which of the following is NOT an example of a secure site through which PHI could be sent electronically? Registries and databases In a medical malpractice lawsuit, the physician would be considered the ________. defendant The legal health record must be maintained according to all of the following except: The OIG work plan Which of the following is true about destruction of the health record? Destruction must be done as part of the organization's usual course of business For which of the following is authorization NOT required for the release of protected health information? All of the above Mary is a coder at ABC hospital. During her review of the documentation in Miss Miller's electronic health record, she reads reports from previous visits. Mary's actions are a violation of ______. the standard of minimum necessary Reimbursement Methodologies Teri is verifying Medicare benefits for a certain procedure. The national coverage determination (NCD) he reviewed does not answer all his questions. Which of the following is the next resource Teri should consult for additional information? Local coverage determinations (LCDs) Fee-for-service reimbursement provided after health services have been given is called____?

retrospective payment Billing for two or three codes when one comprehensive code is more appropriate? Unbundling Capitation, global/prospective payment, and prospective payment are examples of this type of reimbursement method. Episode-of-care Under this reimbursement method, a third-party payer contracts with a healthcare provider to pay a flat fee per individual enrolled in the healthcare plan. Capitation Dr. Johnson recommends a procedure for Mr. Thomas who is a Medicare patient. The procedure is not reimbursed under Mr. Thomas' Medicare policy. In order to bill Mr. Thomas for the procedure, Dr. Johnson's office must collect a(n)____ from Mr. Thomas. advance beneficiary notice of noncoverage Which of the following is NOT an element of the healthcare reimbursement process? clinical documentation review Sue was admitted to ABC hospital as an inpatient. During the admission, Dr. Butler removed her appendix. Dr. Butler would bill for his services with ___ codes submitted on a ____ claim form. CPT; CMS-1500 A pre-existing condition which, because of its presence, causes an increase in length of stay by at least one day in approximately 75% of cases. Comorbid condition Of the following, which does NOT directly influence the assignment of MS-DRGs? Severity of illness Medical Terminology Which of the following terms describes a woman who loses her first pregnancy at 13 weeks gestation? Nullipara A term the is comprised of multiple word roots and a suffix is called a(n) ____. compound word Ichthyosis means: Fishlike or scaly condition The suffix that means surgical puncture

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-centesis The word which means muscle fiber pain. Fibromyalgia Which of the following means lying horizontally on the back, face up? Supine The word that means paralysis of all four extremities. Quadriplegia The word which means loss of hearing due to the natural aging process. Presbycusis Anatomy And Physiology Which of the following is NOT one of the 12 cranial nerves? Radioulnar nerve Which structure contracts to form a slight vacuum in the chest cavity to facilitate inspiration? Diaphragm The elongated middle portion or shaft of a long bone, often referred to as the body. Diaphysis These nerves control the skeletal muscles and parts of the body that are under conscious control: Somatic Which portion of the brain contains structures associated with visual reflexes and hearing? Mesencephalon The three membranes that surround and protect the brain and spinal cord are collectively called: Meninges The ________ of the lung is the medial depression where the primary bronchi and pulmonary blood vessels enter each lung. hilum Involved in both the digestive and endocrine systems, the _________ secretes hormones as well as digestive juices for the breakdown of foods. pancreas Introduction To Coding

From the following list of clinical indicators, what is the diagnosis that is being evaluated? Impaired gag reflex (in patients that are unconscious or semi-conscious) after a stroke or brain injury Esophageal disorder (obstruction, cancer, stenosis, varices) Dysphagia Positive swallowing study Positive infiltrate on chest x-ray Aspiration pneumonia Which of the following takes precedence over the ICD-10-CM Coding Guidelines? Instructions and conventions Which of the following is/was NOT a result of CMS' use of Recovery Audit Contractors (RACs)? Consolidation of Medicare parts A and B This terminology is only used in an electronic health record. SNOMED CT This type of computer-assisted coding uses artificial intelligence and linguistics to extract data from the record and convert it into medical codes. Natural language processing ICD-10-CM Coding Guidelines Codes for signs and symptoms are reported when the provider has documented a related definitive diagnosis. false There is no time frame defining when pain becomes chronic pain. The physician's documentation should be used to determine if the pain is considered chronic. true When a patient has an adverse drug reaction, code both the reaction and the code from T36-T50. true Inoculation and vaccination Z codes can be reported as the first listed or additional codes. true When the cause of an injury is suspected to be the result of terrorism, a code from category Y38 should be assigned. false When a patient with a high-risk pregnancy is being seen for a routine prenatal outpatient visit, the supervision of high-risk pregnancy code should be reported as the first-listed diagnosis.

true The second trimester is defined as 12 weeks 0 days to less than 28 weeks 0 days. false When the physician documents suspected or possible avian influenza, a code from category J09 should be reported. false ICD-10-CM Coding Scenarios A 10-year old male patient is seen in the emergency department for cough, difficulty breathing and wheezing more severe than his baseline. He responds well to treatment with nebulized albuterol and is discharged home with instructions to follow up with his primary care provider. The final diagnosis is: Acute bronchitis superimposed on COPD with asthma of severe persistent type with acute exacerbation. J44.1, J20.9, J45.51 A patient presents with abdominal pain. After a complete work-up the patient is found to have an obstructive diaphragmatic hernia with gangrene K44.1 A 7-year-old child was seen in the emergency room for a dog bite on her left thigh. She received an injection of rabies immunoglobulin since the dog was known to have rabies. S71.152A, Z20.3, W54.0XXA The patient is a 13 yr. old type 1 diabetic with proliferative retinopathy of both eyes who regularly uses insulin for control of blood sugar. E10.3593 A 67-year-old male patient went to his physician's office for a visit for his chronic, systolic CHF and hypertension. After examination, the physician determined the patient's condition is stable and will keep his current medication regimen the same. I11.0, I50.22 A 14-year-old male patient was brought into the emergency room by his parents after he injured his left knee from sliding into third base during a high school baseball game. X-rays revealed a sprained anterior cruciate ligament. S83.512A, W21.89XA, Y92.320, Y93.64, Y99.8 Recurrent tonsillitis and chronic tonsillitis J03.91, J35.01 A 48-year-old female patient was admitted for hemodialysis for acute renal failure. The patient also has stage I chronic renal failure and hypertension.

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N17.9, I12.9, N18.1 Jean came into the office for concerns of frequent urination, and a migraine headache with aura and associated facial pain which she has had for 3 days. She has taken her migraine medicine with no relief. The physician performed a urinalysis with microscopy, and a 2 view paranasal sinus x-ray. The urinalysis revealed gross hematuria. The x-ray revealed acute maxillary sinusitis. Assessment: urinary tract infection, intractable migraine with status migrainosus, and acute maxillary sinusitis. G43.111, J01.00, N39.0 A 17-year-old male patient was taken to the emergency room because of third degree burns to his chest wall and abdomen. He also has third degree burns to both upper arms and forearms. The patient fell into a bonfire T21.31XA, T21.32XA, T22.312A, T22.332A, T22.311A, T22.331A, X03.0XXA A 33-year-old female patient comes into the office today with complaints of chronic coughing and wheezing. The physician sends her to the hospital for chest x-rays. The final diagnosis for the office visit is coughing/wheezing, rule out mild persistent asthma. R05, R06.2 Polyneuropathy secondary to rheumatoid arthritis of the right hand M05.541 A 32-year-old female patient was brought to the emergency department by her husband for difficulty walking. They had been at a party at a friend's house where the wife had taken Valium as prescribed by her physician and consumed three martinis. The patient was examined and monitored for 12 hours and then discharged. The final diagnosis was documented as: Overdose secondary to abuse of Valium and alcohol with resulting ataxia. T42.4X1A, T51.0X1A, R27.0, F10.10, F13.10, Y92.019 Impending myocardial infarction I20.0 The patient is a newborn, delivered by cesarean section secondary to persistent occiput posterior presentation with obstruction. Upon examination the patient was normal with the exception of caput succedaneum secondary to sitting in the birth canal for so long. Z38.01, P12.81, P03.1 CPT/HCPCS Coding Guidelines Wound closure consisting of steri-strips alone is classified as a simple repair. false The reporting of test results with medical interpretive judgment is considered a clinical pathology consultation.

true Services performed to manage postoperative complications are included in the surgical package therefore they are not reported separately. false The codes 31233-31298 are used to report bilateral procedures unless otherwise specified. false For excision of benign lesions requiring more than simple closure, an intermediate or complex closure code should be reported in addition to the excision code. true Routine postoperative followup care is not covered under the surgical global package. false Follow-up care for therapeutic surgical procedures includes care for complications, exacerbations, recurrences or the presence of other disease or injuries. false When multiple procedures (other than E/M services, physical medicine and rehabilitation services, provision of supplies, or add-on codes) are performed at the same session, by the same individual, the additional procedure or service is identified by appending modifier 51 to the additional procedure or service code(s). true Endovascular Revascularization codes 37220-37235 are built on progressive hierarchies with more intensive services inclusive of lesser intensive services. true If tests are performed in addition to the tests included in a particular organ panel, those tests should be reported separately. true When a Category III code is available, this code is reported instead of an unlisted code. true A chief complaint is a concise statement describing the symptom, problem, condition, diagnosis or other factor that is the reason for encounter. true The Radiological Supervision and Interpretation codes are not applicable to the Radiation Oncology subsection.

true Add-on codes are exempt from the use of modifier 51. true The key components that are reviewed in order to assign a correct E/M code are history, review of systems, and medical decision making. false CPT/HCPCS Coding Scenarios Bilateral salpingo-oophorectomy. With the patient under adequate general anesthesia, she was in the supine position prepped and draped in the usual fashion. Low transverse incision of the Pfannenstiel type was made through the skin, subcutaneous tissue, fascia, and peritoneum. The upper abdominal viscera were examined and found to be normal. The pelvic organs were examined and the left ovary was composed of multiple small cysts. The right ovary was normal. Both ovaries and tubes were removed using 2-0 Vicryl stick ties for hemostasis of the infundibulopelvic ligaments. The anterior peritoneum was closed with running double 0 chromic, double Vicryl was used to close the fascia, 3-0 Vicryl the subcutaneous, and 4-0 Vicryl for subcuticular closure. The patient tolerated the procedure well and was transferred to the recovery ward in satisfactory condition. 58720 Primary low transverse cesarean section. After the patient was appropriately consented, consent was signed and placed in the chart. The patient was taken to the operating room. Epidural anesthesia was dosed. Subsequently, patient prepped and draped in the usual sterile fashion. A Pfannenstiel skin incision was carried down to the level of the fascia. The fascia was explored and dissected off the rectus muscle. Muscle was split in the midline. Peritoneum entered bluntly and incision extended superiorly and inferiorly. Bladder blade was placed in. Visceroperitoneum was dissected. Lower uterine incision was created with sharp scalpel and infant delivered in breech presentation without any difficulty. Bulb suction of the oropharynx and nasopharynx and handed to pediatric nursing in attendance. Cord blood was obtained. Placenta was delivered. Uterus was externalized. Intrauterine cavity cleaned with clean laps and bilateral tubes and ovaries appeared normal. Uterine incision was closed with 0 chromic running locking fashion and figure-of-eight suturing. The uterus was placed into the abdominal cavity. Copious amount of irrigation was used. Muscle was approximated with 2-0 chromic. Fascia was closed with 0 Vicryl. Subcutaneous tissue irrigated, small bleeders were electrocauterized and the skin was closed with staples. Needle, instrument and lap counts were correct and accounted for times 2. The patient was taken to the recovery room in stable condition. Code as if the physician were providing the above services only. 59514 A 36-year-old male patient came into the orthopedic surgeons' office 3 days after being in the emergency room. He had fallen off the ladder at home and hurt his ankle. This is the patient's initial visit. The physician performs a detailed history, an expanded problem focused exam; medical decision making is low complexity. The physician performs and interprets a left ankle x-ray 2 views. The physician interprets the x-ray that the patient has a closed bimalleolar fracture on the left ankle. He treated this

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closed fracture bimalleolar fracture without manipulation by applying the initial cast while the patient is in the office. 99202-25, 27808-LT, 73600-LT Philip, a 60-year-old male patient, has end-stage renal failure and comes to the laboratory today for his monthly urinalysis (qualitative, microscopic only). 81015 This patient is returning for evaluation of right heel pain that has been evident now for a year and a half. It is worse with activity. He has been on Motrin without significant benefit. Inserts have been used with marginal help. This area was injected with 10 mg of Kenalog-40. The procedure was tolerated well. No other intervention at this time. 96372, J3301 This 40-year-old male patient with a history of poorly controlled diabetes has had a wound on the medial portion of his left lower extremity for approximately 10 days. He does not recall a specific bite but believes it may be due to an insect bite. It has been draining purulent material. The leg has been more red and swollen than normal. The patient states that his leg is normally chaffed, swollen, and somewhat erythematous secondary to his diabetes and poor circulation. Denies any fevers or chills. Patient cannot recall when his last tetanus update was, so we did that today. 90714, 90471 A patient with stress incontinence requires repair for cystocele and incomplete vaginal prolapse. The physician elects to perform a paravaginal defect repair. An abdominal incision is made and entry into the space of Retzius gland. Six sutures are placed through the anterior lateral edge of the vaginal wall and then through the fascia condensation over the obturator internus muscle to the inferior aspect of the pubic bone along the arcus tendinous to the ischial spine. Additional anchors were placed at the level of the urethrovesical junction to correct the cystocele. 57284 What is the type of sedation that allows a procedure to be performed without pain to the patient when the patient is not completely asleep? conscious or moderate Patient is a 79-year-old male who presents today with complaints of a three-day history of nausea and vomiting with last episode occurring the last night. He has a history of anorexia. Bowel movements include one two days after leaving the hospital that was small, one episode of diarrhea four days later, and then another very small, firm bowel movement today. He has lost 12-15 pounds in the last 10 days and reports difficulty swallowing meals. Radiologic exam of the upper gastrointestinal tract with KUB was performed, flat and upright. The image was read as nonspecific small bowel-gas, including colon was full of stool. PLAN: Magnesium citrate one bottle to be drunk when he gets home. Dulcolax suppository per rectum q. 6h. for constipation. The patient has also been advised to return to the emergency room if his condition worsens.

74240 A 38-year-old female patient was admitted to Harper Hospital on 2/19/xxxx with a diagnosis of a herniated disk C6-7. She is being taken to the operating room for a C6-7 hemilaminectomy. Specifically, a laminotomy (hemilaminectomy) was performed with decompression of nerve roots and excision of herniated intervertebral disk, one interspace, cervical. An arthrodesis was also performed, single level cervical below C2 segment. 63020, 22600 A 45-year-old male patient was admitted to the hospital for an excision of a parotid tumor or gland or both. The patient was taken to the operating room and was put under general anesthesia. Dr. Derek Shepherd opened the area and exposed the parotid gland. Due to the size of the tumor (5.0 cm), the decision was made to remove the entire gland. With careful dissection and preservation of the facial nerve, the parotid gland was removed. Patient was taken to the recovery room in good condition. 42420 The patient is here today to follow up on his chronic renal failure. He is a 59-year-old with multiple medical problems including complicating diabetes with severe neuropathy and idiopathic dilated cardiomyopathy. Laboratory today: Glucose 224, sodium 139, potassium 4, chloride 96, carbon dioxide 34, urea nitrogen 4, creatinine 2.2, total calcium 8.9, and phosphorus 3.2. The patient needs to continue current treatment. Also reemphasized the salt restriction to 2 grams per day and moderation in protein intake to 0.6 gram per kilogram per day. 80048, 84100 The patient is here for a follow up of his nonhealing left great toe ulcer. Examination of his nonhealing wound showed it to be essentially covered up with callous and suboptimal tissue. This was debrided back at the bedside to healthy granulation tissue at his first consultation. Since this time he has been undergoing wet-to-dry dressing changes b.i.d. via his wife who is experienced in this technique. Examination of his ulcer today shows a very well taken care of ulcer. There is beefy granulation tissue at the bed of the majority of the ulcer. The ulcer today measures approximately 1 cm in diameter. Selective debridement down to the level of the bone was done to remove fibrinous exudate at the base of the wound. As mentioned before, the rest of the wound shows very good granulation tissue. 97597 A 29-year-old patient is referred for placement of a tunneled central venous catheter with subcutaneous port. To facilitate the advancement of the catheter and ensure accurate placement fluoroscopy is used. 36561, 77001 A 51-year-old male patient comes in for his chemotherapy treatment. The chemotherapy is injected into the pleural cavity with thoracentesis. 96440 This patient has been treated for Crohn's disease of the small intestine. She has had several exacerbations but has been maintained on drug therapy. She is being seen now for extreme pain, which

on x-ray shows small bowel obstruction. Patient will be taken to surgery immediately. During the surgery a partial excision of the terminal ileum was performed to release the obstruction. There was also a resection of the jejunum that was very inflamed. An end-to-end anastomosis was completed on both segments. The patient tolerated the procedure well. 44120, 44121 Susan is a 32-year-old patient who has a suspicious tumor in the lower outer quadrant of the left breast. The physician discusses a treatment option with her in the event carcinoma is found, including immediate reconstruction following mastectomy. On 1/12/xxxx she had excision of the tumor, which the physician had previously identified by placing a radiological marker in the left breast. A frozen section revealed infiltrating ductal carcinoma in the left breast. With the patient still under general anesthesia, the physician performed a left modified radical mastectomy with axillary lymph node removal and removal of pectoralis minor muscles only. Immediately following the mastectomy, the patient had a breast prosthesis (reconstruction) of the left breast. 19307-58-LT, 19340-58-51-LT, 19125-51-LT Aaron, a 33-year-old male patient, has been suffering from chronic fatigue. His physician sent him to the laboratory to have a TSH test run. 84443 Repair of extensor tendon and lateral band extensor tendon. After sterile preparation and draping in the normal sterile fashion, regional block anesthesia, and tourniquet exsanguination of the finger with a Tournicot, the tendon was approached using 4-0 and 6-0 Prolene. A modified Kessler suture was placed in the central slip portion of the tendon, after debridement and reapproximation using a horizontal mattress suture. After the 4-stranded technique repair, 6-0 Prolene was used to give smoother alignment to the central slip. Next, the lateral band extensor tendon was approached. A horizontal mattress suture was followed by a modified Kessler suture, followed by a 6-0 running suture in order to allow smoother gliding and less adhesions of the tendon. This tendon also required some debridement prior to realigning the tendons. The patient tolerated the procedure well. No complications occurred throughout. The skin was closed using 4-0 Prolene suture after the procedure. Good function, flexion, and extension of the tendon occurred after the procedure. He will follow back up for re-evaluation in a week or 2. 26418, 26418 A 68-year-old male patient went to the ASC for a colonoscopy. The physician administered the patient with Versed, inserted the endoscope, and inspected the descending colon. The procedure could not be finished because the patient went into respiratory distress. The patient was stabilized and the procedure was discontinued. What modifier would be appended to the colonoscopy code to indicate that the procedure was discontinued? 74 Amy was admitted to the hospital on 1/25/xxxx because of an abnormal Pap smear and excessive vaginal bleeding. Dr. Bailey referred this patient to Dr. Grey, who did a consult on 1/26/xxxx where she performed a comprehensive history/exam; the medical decision making was of moderate complexity. After speaking with the patient & reviewing the patient's ultrasound, which revealed a uterine fibroid, it

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was decided the patient would have surgery on 1/27/xxxx. The patient was taken to the OR where Dr. Grey performed a vaginal hysterectomy >250 grams, with removal of tubes, ovaries and repair of enterocele. Code Dr. Grey's services. 99254-57, 58292 Modifier -58, staged or related procedure or service by the same physician during the postoperative period, is used to indicate _____. That a subsequent surgery was planned at the time of the first surgery. A 2-year-old boy was born with a cleft lip and nasal deformity. He was admitted to the hospital and taken to the operating room. Dr. Mark Sloan performed a primary complete plastic repair of the cleft lip and nasal deformity, unilateral. 40700 Mary Ellen, a 42-year-old female, was diagnosed with a malignant tumor of the thyroid. She has been admitted to the hospital, brought to the operating room and prepped in the usual fashion. Procedure performed: thyroidectomy, total for malignancy, with radical neck resection.60254 60254 Katie, a 12-year-old, went in for a 2-year followup comprehensive ophthalmologic exam. The physician fits and gives directions about her new contact lenses. She is to follow up in 1 week to see how her contacts are working. Correct Answer 92014, 92310 92014, 92310 An 18-year-old female patient presented to the hospital laboratory department for drug testing. A basic three-panel drug screen for barbiturates using a self-contained, cup type drug test screening kit is performed.80345 80345 The patient was taken to the Cardiac Catheterization Lab in a fasting condition. Bilateral groin areas were prepped and draped in the usual sterile fashion and the 5-French sidearm sheath was introduced into the right femoral artery using a modified Seldinger technique. A 5-French JL5 catheter was used for left coronary angiography and a 5-French JR4 catheter was used for right coronary angiography. Attempts were made for a 5-French pigtail catheter to pass the aortic valve unsuccessfully, despite using stiff wire. Therefore, the decision was made to exchange the 5-French sidearm sheath for a 6-French 45 cm sheath and a 5-French pigtail catheter was introduced into the left ventricle and LV-gram was recorded. At the end of the procedure all catheters were removed, and manual pressure followed by FemoStop and additional pressure were applied on the right femoral artery site. Impression: Three-vessel coronary artery disease proximal LAD 90%, D1 70%, D2 50%, left circumflex proximal 70%, and mid 80%, RCA mid 99% with collaterals from septal to PD and OM to PL.93458 93458

Right upper eyelid blepharoplasty. After preoperative markings and infiltration with local anesthetic using lidocaine with epinephrine and regional block anesthesia with Marcaine and epinephrine, the superfluous, excess skin that was weighing down the lid was marked in an elliptical fashion, symmetrically from side-to-side, leaving approximately 8 mm of skin above the lash line. The superfluous skin was excised and closed under no significant tension using a running intracuticular 5-0 Prolene suture. Only a very small slip of muscle in the central portion was removed laterally. The patient understands those limitations and the minimal improvement that could be done medially because of the contour of her eyelid skin, in order to prevent excess scarring. The patient tolerated the procedure well. Hemostasis was maintained meticulously throughout the surgery using heat cautery. The patient tolerated the procedure well and was discharged home. She was dosed with preoperative antibiotics and will follow up for suture removal in about 10 days. 15823-E3 Penile warts. The patient had numerous lesions treated today with liquid nitrogen for two freeze/thaw cycles for five to ten seconds to all. The patient tolerated the procedure well and is aware of the sequelae. We have discussed condom use and post care with liquid nitrogen to avoid any frictional or irritational activity to this site. The patient should wait about two to three weeks, and then he should start using Aldara cream on all of the warts q.h.s. for three nights per week, such as Monday, Wednesday, and Friday. I gave him enough for six nights on a trial basis since he is diabetic. This will help his system to fight off and cause the warts to regress. If he does not develop any irritation or reactions to the Aldara, this would be a good way to have him use home therapy in the future.54065 54065 Open fracture dislocation, PIP joint. Manipulation reduction, wound debridement, and immobilization. The patient's finger was originally inspected; anesthesia was injected in a digital block form. After complete anesthesia was obtained, the patient's finger was hyperextended and the PIP joint reduced. The wound was then copiously irrigated. The small opening was extended in a volar Brunner type fashion. The skin flaps were opened and wound was carefully debrided and extensively irrigated. Gross sand and dirt material was identified and removed. Flexor tendon sheath was opened and similarly cleansed. Tendons themselves did not appear to be injured. The joint was opened and carefully inspected and irrigated. No gross contamination was found in the joint itself or on the articular surfaces. After copious irrigation, the volar plate was repaired. The incision was repaired, but the wound was allowed to remain open. The joint was tested for stability and fond to be stable in the radial and ulnar deviation and stable to dorsal volar motion in a 30 degree flexed position. Full extension resulted in some instability and therefore an extension-blocking splint was applied. Sterile dressing was placed and the patient was discharged home to his own care. 26725, 26548-51, 11010-51 Steroid injection into deQuervain's tendinitis area and injection into separate ganglion cyst. 20 mg of Kenalog were drawn up and diluted with equal amounts of Marcaine and injected along the tendon sheath involving the deQuervain's disease. After the injection was accomplished, a separate syringe containing 10 mg of Marcaine was used for injection into the cystic area or the lesion area of the ganglion cyst area. First, the lesion was drained, and following this, injection of 10 mg of the Kenalog was

injected into the cyst. The patient had no changes in her history or physical exam. She will follow up p.r.n. if she has any problems or if she has a recurrence. 20550, 20612-51, J3301(3) Katie went to the office to see Dr. Mark Sloan for several scars on her face cause by acne. Dr. Sloan decides to do an epidermal chemical peel of the face. 15788 Lynda, a 52-year-old patient of Dr. Bailey, had been diagnosis with stage IV endometriosis as well as a pelvic floor defect. The patient was admitted to the hospital for her surgery. The patient was taken to the operating room and prepped in the usual fashion. Dr. Bailey performed a total abdominal hysterectomy with an anterior/posterior colporrhaphy and an enterocele repair. The patient tolerated the procedure well and was taken to the recovery room. Code as if you work for the hospital. 58150, 57265 A 68-year-old male patient is seen in the Radiation Oncology Department at the hospital for secondary prostate cancer. The primary site was the lower lobe of the lung. The oncologist, who is an employee of the hospital, performs complex clinical treatment planning, basic dosimetry calculation, and a complex isodose plan; treatment devices include blocks, special shields and wedges. The patient had 5 days of radiation treatments for 2 weeks, a total of 10 days of treatment. Report the physician service. 77263, 77307, 77334, 77427x2 A 46-year-old female patient was admitted to the hospital. She was taken to the operating room to have a percutaneous transluminal angioplasty due to insufficient hemodialysis based on segmental stenosis of the fistula/cephalic vein. The percutaneous transluminal angioplasty involved navigating through the radial artery into the cephalic vein to accomplish repair and a dialysis fistula angiography. 36902 Dave, a 38-year-old male patient with chronic sinusitis went to the ASC to have endoscopic sinus surgery performed. The physician performed an endoscopic total ethmoidectomy with an endoscopic maxillary antrostomy with removal of maxillary tissue. The patient was taken to the recovery room in satisfactory condition. Code as if you work for the physician. 31255, 31267-51 The patient had a raised mole under her right breast that is continually irritated from her underwire bra rubbing on it and causing it to bleed. After local anesthetic, the mole, measuring 2.5 cm, was excised and placed in a vial of formalin, labeled, and sent for pathology. The defect was closed with Steri-Strips and the patient was instructed on wound care. The pathology report came back four days later showing the mole was benign.11403 11403 Katie, a 13-year-old, is in for a 2-year follow-up comprehensive ophthalmologic exam. Correct! 92014

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92014 Right carpal tunnel release. The patient was brought to the operating room, and Bier block anesthesia was performed. The right upper extremity was prepped and draped in the usual sterile manner. A longitudinal incision was made along the thenar crease in the right palm. This was carried sharply down through the skin and subcutaneous tissue to the transverse carpal ligament. The carpal ligament was then carefully incised using a push technique with a 15 blade. The recurrent branch of the median nerve was identified on the distal extent of the transverse carpal ligament. It was intact. The other digital nerves were found coming off the median nerve and were intact. The median nerve was found to have an hourglass deformity with some bluish discoloration. An aponeurotomy was performed using a 15 blade and smooth pickups. The floor of the carpal canal was explored, and there were no masses. There was no significant synovitis of the flexor tendons. Baby Metzenbaums were then used to finish the carpal tunnel release up into the volar forearm using a push technique. The volar and dorsal aspects of the carpal ligament up into the forearm were cleared of tissue, and then the ligament was transected. The wound was irrigated profusely. The wound was closed using 4-0 nylon in a horizontal mattress suture. Xeroform, fluffs, Kerlix, and a volar splint were applied. Tourniquet time was 30 minutes. Complications: None. Fluids: 1,000 cc. 64721-RT John, a 73-year-old patient, was admitted to the hospital to have a single-chamber temporary pacemaker implanted because of his supraventricular tachycardia. He was taken to the operating room. The right subclavian area was prepped and draped in the usual fashion. Local anesthetic was infiltrated. The subclavian vein was entered via Seldinger technique with a Cook needle. A guide wire was passed to the right heart. A 6-French dilator sheath was placed. The dilator and wire were then removed. The sheath was sutured into place. A 5-French bipolar pacemaker wire was placed near the apex of the right ventricle. Temporary pacing was instituted. Threshold was less than 0.5 mV. Pacer settings were 60 per minute demand and 5 MA. Patient returned to his room in good condition. 33210 This 55-year-old patient was seen previously for a laparoscopic biopsy of her cervical lymph nodes. The biopsy came back showing abnormal cells. The decision was made to do a lymphadenectomy (modified radical neck dissection). The patient was brought to the operating room and put under general anesthesia. The lymphadenectomy was performed and the patient was returned to the recovery room in satisfactory condition.38724 38724 Sarah, a 40-year-old female new patient was seen in the clinic by Dr. Izzy Stevens for fever, flank pain and blood in the urine. Dr. Stevens performed a comprehensive history and examination. The medical decision making was of moderate complexity. The diagnosis of urosepsis and bacteremia was made. The patient was given an IM injection of Rocephin 250 mg, under direct physician supervision. 99204-25, 96372, J0696 Extracorporeal shockwave lithotripsy of right kidney stone. Under IV sedation the patient was placed in the supine position. The stone in the upper right kidney was positioned at F2. Then the extracorporeal

lithotripsy was started at 19 KV. Subsequently the KV was increased to a maximum of 26 KV at 1,600 shocks. The stone was revisualized and repositioning was done considering the transverse colon passing right anterior to the stone. With repositioning completed, the stone appears to be in the same place therefore, shocks were delivered. A total of 2,400 shocks were delivered with apparent adequate fragmentation obtained.50590-RT 50590-RT This patient injured his left foot on a garden hoe. He severed the superficial branch of the external plantar nerve. The patient experienced loss of sensation on the outer side of the fifth toe and across the side of the foot. Following exploration of the wound and identification of the nerve avulsion a repair of the nerve was undertaken using a nerve graft from the sural nerve. A lateral incision was made on the lateral mallelous of the ankle. The nerve was identified and freed for grafting and the proximal and distal sural nerve endings were anastomosed. The wound was dissected and the damaged area of the area was removed. The innervation of the external digital nerve was restored by suturing the 2.0 cm graft to the proximal and digital ends of the damaged nerve using the operating microscope. The wound was closed in layers. 64890-LT, 69990 A 44-year-old male patient underwent a colon resection for adenocarcinoma one and one-half years ago. Following the left colon surgery, he received systemic chemotherapy. After six months of treatment, the patient's carcinoembryogenic antigen (CEA) began to rise. CT imaging of the liver revealed three lesions along the anterior and inferior surfaces of the right lobe of the liver. All three lesions were confirmed on ultrasound examination and were felt to be superficial and accessible by laparoscopy. The lesions measure 4 cm, 2.0 cm and 2.5 cm in diameter. The physician performed a laparoscopy surgical ablation, cryosurgery technique using ultrasonic guidance (supervision and interpretation). All three lesions were ablated by cryosurgery. 47371, 76940-26 What code(s) would you use to report chemosurgery, Mohs' micrographic technique, with six specimens of fresh tissue trunk, first stage? 17313, 17314 A 42-year-old female new patient went to see Dr. Shepherd for her migraine headaches. Dr. Shepherd took a comprehensive history. The patient explained she is now getting auras with her headaches and sometimes she even has passes out. She informed the physician her sister suffers from migraines, as did her mother; however, the mother passed away from a ruptured aneurysm. The patient is concerned about this because she is nearing the age that her mother passed away. Dr. Shepherd performed a detailed exam. When listening to the carotid bruits there was a high pitch thrill. The abdominal aorta bruit was normal. The medical decision process was of high complexity. The patient was currently having an intractable migraine with aura. She has been taking her Topamax, took an Imitrix at 5 am, and a Fiorcet at 5 am with no relief. The physician explained he was ordering an MRA of the brain and an ultrasound of the carotids be to done today if possible; if not, tomorrow morning. He also was going to have the medical assistant withdraw some blood to send to the lab for CMP panel. He gave her an

injection of 60 mg of Toradol (ketorolac tromethamine) IM, 6mg of Imitrex SC for relief of her headache. He will call her with the results of the MRA and the ultrasound. 99203-25, 96372x2, J1885x4, J3030 Theresa came into the office to see Dr. Grey for Aspiration/injection into her left knee. The patient has osteoarthritis of the knee. The knee was prepped. She was injected with Synvisc 16 mg into the knee. 20610-LT, J7325x16 The patient is a 77-year-old male who has a history of chronic renal disease, which had been noted most recently when he was followed by his primary care doctor for hypertension. The patient has a history of dizziness; it is not clear whether this is vertigo or whether these are symptoms syncopal in nature. Otherwise, he feels fairly stable. Laboratory taken in office today reveals his BUN and creatinine to be 19 and 2.2 respectively, which have been fairly stable. His H&H are 11.6 and 35.8 also respectively. So, we have a patient with chronic renal disease, cause unclear, but without significant proteinuria and who has a history of hypertension, which now is fairly well controlled, but probably has ischemic heart disease as well. 84520, 82565, 85014, 85018 A 55-year-male patient went to the ambulatory surgery center for his colonoscopy. The physician anesthetized the patient with Versed, inserted the endoscope, and inspected the descending colon. However, he could not finish the procedure because the patient went into respiratory distress. The patient was stabilized and the procedure was discontinued. What modifier would be applied to the colonoscopy code to indicate that less than the code definition was performed? 74 Outpatient Practicum Pathology Report SPECIMEN: Bronchial brush, lung, left upper lobe. GROSS DESCRIPTION: Bronchial brush, lung, left upper lobe: (Cytology and cell block preparation) MICROSCOPIC: Positive for malignant cells, non-small cell carcinoma, most consistent with adenocarcinoma. The cytomorphology of current specimen is similar to this patient's previous lung cancer specimens which were reviewed and compared at this time. DIAGNOSIS: Non-small cell carcinoma, left upper lobe. C34.12, 88305 Progress Note CHIEF COMPLAINT: Left inguinal hernia. HISTORY OF PRESENT ILLNESS: This established patient is a 59-year-old male who has a three-month history of a tender left inguinal hernia. The patient first noticed it as a nurse practitioner for this problem in _____[DATE]. The patient describes the pain as being constant but mild. The hernia is reducible. The patient reports the hernia is also warm; however, the patient denies any changes in bowel or bladder habits, any blood in the urine or stool, or any nausea or vomiting. Patient also denies any change in stool caliber. PAST MEDICAL HISTORY: The patient has had a sinus operation 15 years ago. The patient has hypercholesterolemia, as well as tinnitus. Tinnitus was diagnosed last year. ALLERGIES: THE PATIENT HAS NO KNOWN MEDICAL ALLERGIES. CURRENT MEDICATIONS: The patient takes gemfibrozil 600 mg p.o. b.i.d., ibuprofen 800 mg p.o. t.i.d. p.r.n., simvastatin 20 mg q.h.s. SOCIAL HISTORY: The patient has never been a smoker. The patient denies

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alcohol use and other illicit drug use as well. The patient has an EMS and heating plan at the ___[HOSPITAL]. The patient has been divorced for three years and currently lives by himself in _____[PLACE], and he has three children, all sons. FAMILY HISTORY: Family history is negative for coronary artery disease, strokes, cancer, and diabetes. REVIEW OF SYSTEMS: The patient reports he has had approximately a 10% weight loss in the past couple of months anyway; however, this weight loss has been permissible. Otherwise, review of systems is noncontributory. The patient denies chest pain, palpitations, or syncope. Denies shortness of breath or wheezing. Denies nausea or vomiting. Denies headaches or syncope. PHYSICAL EXAMINATION: GENERAL: This is a 59-year-old white male, awake, alert, and oriented x 3, very pleasant to talk to, who is sitting comfortably in a chair in no acute distress. VITAL SIGNS: Temperature 97.0, heart rate 75, respiratory rate 20, blood pressure 156/101. Patient has a 98% saturation on room air. HEENT: Head is normocephalic, atraumatic. Pupils are equally round and reactive to light and accommodation. Extraocular muscles are intact. There is no icterus. Mucous membranes are moist. NECK: The neck is supple with good range of motion. Trachea is midline. There was no JVD or lymphadenopathy present. CHEST: The lungs are clear to auscultation bilaterally. HEART: Regular rate and rhythm without murmur. ABDOMEN: Soft, nontender, nondistended. Bowel sounds are present. EXTREMITIES are warm. There is no clubbing, cyanosis, or edema noted. GU EXAM: Patient has a readily apparent left inguinal hernia. The sac will pulse or bulge with any increase in intra-abdominal pressure. The hernia is reducible. It is also tender to palpation. RECTAL EXAM: The patient has normal sphincter tone. There is stool present in the vault; however, there is no gross blood present on examination. Prostate is enlarged but soft. ASSESSMENT/PLAN: The patient is a 59-year-old white male who is here for a preoperative history and physical. The patient is otherwise healthy. The patient is scheduled to have a left inguinal hernia repair done on _____[DATE]. Correct Answer Z01.818, K40.90, E78.00, 94760 Z01.818, K40.90, E78.00, 94760 Operative Report DIAGNOSIS: AVN and degenerative joint disease (DJD), right hip. PROCEDURE: Right total hip replacement. ANESTHESIA: General. SURGEON: Dr. ____[NAME] INDICATIONS: This gentleman is a young individual who had a previous accident with a fracture of his pelvis at that time and repair of his acetabulum on the right. He has had a previous total hip on the opposite side. He is now here for replacement of his hip on the right, secondary to post traumatic AVN and DJD. DETAILS OF PROCEDURE: The patient was anesthetized with general anesthetic. The leg was prepped and draped in the lateral decubitus position. The old incision was reopened with dissection carried down through scar tissue to expose the short rotators which were dissected from the point of insertion. Soft tissue was then reflected back over the sciatic nerve and held with three stay sutures. The hip was then dislocated easily without problems. In order to get to this point, a large section of ectopic bone had to be dissected free of the soft tissue. Once the hip was exposed, the neck was marked with an osteotome using a cutting guide as an indicator and then sectioned using a power saw. The shaft was then retracted out of the way. The acetabulum thus visualized was clean of soft tissue, both at the margin and at the base with hemostasis being controlled by diathermy. The socket was then reamed using rotating reamers up to size 54, and a trial of a test cap at this time was very satisfactory. Some of the reamings from the acetabulum were then packed in using the reamer in reverse. A 54-mm, porous-coated, ceramic, ExacTech cup was tapped into place and secured with two dome screws, 125/120 6.5 mm diameter. A 28-mm liner was then snapped in place with a 20-degree flange. The femoral canal was then broached with a cookie cutter, tapered reamers, straight reamers, and then broached to accommodate a #5 stem. Test abduction

with the standard head was excellent and therefore these components were selected. The real stem was then tapped home. A ceramic standard neck was then placed in position and the hip reduced. The wound was then closed over a ConstaVac drain brought through a separate stab wound. Closure was by Vicryl interrupted sutures in the deep tissue, continuous for the fascia, interrupted for the subcutaneous, and continuous for the skin. The wound was dressed with antibiotic ointment, Adaptic dry dress, and placed in a pillow. The patient was then deanesthetized and returned to the recovery room for routine postoperative care and x-ray. M87.250, M16.51, S32.9XXS, Z96.642, 27130-RT Operative Report PREOPERATIVE DIAGNOSIS: Nevus of the midback and nevus of the left lower back. POSTOPERATIVE DIAGNOSIS: Nevus of the midback and nevus of the left lower back. PREOPERATIVE SIZE: Midback 0.8 x 0.6 cm; left lower back 0.6 x 0.4 cm. POSTOPERATIVE DEFECT SIZE: Midback 3.0 cm; left lower back 0.6 cm. PROCEDURE: Excision of nevus, mid-lower back with intermediate closure; punch biopsy of nevus, left lower back. DESCRIPTION OF PROCEDURE: The relevant risks and aspects, as well as the rights of refusal were explained to the patient. The informed consent was obtained and placed on the chart. The patient was brought to the operating suite, and the 2 areas on the back were prepped and draped in the usual sterile manner. A fusiform shape was drawn around the lesion on the mid-lower back. The area was then infiltrated with anesthetic. A #15 scalpel was used to excise down to the level of subcutaneous fat. The tissue was removed and sent to pathology. Hemostasis was maintained with electrocautery. The subcutaneous layer was closed with three sutures of 4-0 Vicryl. The cutaneous layer was reapproximated with a running suture of 4-0 nylon. A 6-mm punch biopsy was used to remove the nevus of the left lower back. The cutaneous layer was closed with 3 sutures of 4-0 nylon. ANESTHESIA: 5 cc of lidocaine with 1:100,000 epinephrine. ESTIMATED BLOOD LOSS: Minimal. COMPLICATIONS: None. DISPOSITION: The patient was alert and oriented times 3 post procedure and tolerated the procedure well. He was given both verbal and written wound care instructions. He is to follow up on Friday _____[DATE] for suture removal. D22.5, 11401, 12032-51, 11104-51 Emergency Department Report SUBJECTIVE: The patient is a 56-year-old white male with a history of some sort of thyroid cyst, who comes in today complaining of an abscessed tooth. He says that he had one before on _____ [DATE] and this feels just the same. He does not currently have an appointment with the dentist. He is having a low-grade fever and he wants antibiotics at this time. The patient also has a history of thyroid cyst that was removed several years ago, and he says that since that time he has been requiring calcium and magnesium supplementation. His surgery was done at ____[HOSPITAL]. He also says because of the calcium metabolism abnormalities, he had several fractures in his spine at an early age. OBJECTIVE: He has erythema and swelling of his left upper gum with numerous caries. No lymphadenopathy. HEART: Regular rate and rhythm without murmur. LUNGS are clear. DIAGNOSTIC IMPRESSION: 1. Tooth abscess. We plan to give the patient clindamycin 300 mg q.i.d. for 10 days and have him set up a dental appointment next week, which the patient will make. 2. History of thyroid cyst removal and possible need for calcium and magnesium supplementation. We will get the patient's records from ____[HOSPITAL] and arrange a primary care appointment visit for this patient. Correct Answer K04.7, Z86.39, 99281 K04.7, Z86.39, 99281

Pathology Report SPECIMEN: Toe, right 3rd, amputation GROSS DESCRIPTION: An amputated distal phalanx, 2.6 cm from the tip of the toe up to the soft tissue and bone resection margin 1.8 x 1.8 cm. There is a healed ulcer at the tip of the toe measuring 0.8 cm. The skin is tan with an intact nail present, 0.7 cm. The skin, soft tissue and bone at the surgical margin grossly appear viable. The specimen is decalcified and representative sections are submitted. MICROSCOPIC: The skin is ulcerated with necrotic and fibrinopurulent debris at the ulcer surface and gangrenous tissue in the ulcer bed. Adjacent epidermis is hyperplastic. Underlying the ulcer, the bone cortex is eroded, with fibrosis and osteoblastic and osteoclastic activity. In the deeper intertrabecular space, there is fibrosis and minimal chronic inflammation and focal necrosis with a few degenerated neutrophils. In the soft tissue of the subcutaneous area is a focus of fibrosis containing deposits of amorphous material surrounded by histiocytes, foreign body giant cells and few lymphocytes. There is no malignancy. DIAGNOSIS: Acute and chronic osteomyelitis and ulceration with gangrene. M86.171, M86.671, I96, L97.511, 88305, 88311 Emergency Department Report SUBJECTIVE: The patient is a nurse here who while changing work assignments was walking down the hall between units, tripped and fell and felt a pop in his right upper arm and shoulder and lots of pain there afterwards. He states that he has pain when he tries to abduct his shoulder or extend his shoulder, also pain with extension of his arm at the elbow. He denies having pain like this before. EXAM shows pain with abduction or extension both passive and active. He does have some pain on palpation of the lateral shoulder. No evidence of muscle rupture. No muscle balling or bulging. No tenderness in the muscle. He can flex the biceps without much pain but has pain with extension. Complete shoulder x-ray shows no dislocation or fracture of his right shoulder joint or humerus. ASSESSMENT/PLAN: Right shoulder muscle sprain. The plan at this time is to ice the shoulder. I gave him an arm sling to wear for comfort. He is to rest it and take ibuprofen 400 to 600 mg q.6-8 hours p.r.n. pain; a prescription was given to the patient. He should be on light duty for the next 10 days and should not lift more than 10 pounds. I told him to wear the sling for comfort, but to make sure he maintains range of motion in the shoulder. If he continues to have pain or pain worsens, he needs to come in to be re-evaluated. S43.401A, W18.39XA, Y92.232, Y93.01, Y99.0 73030-TC-RT Progress Note TIME IN: 1000 TIME OUT: 1020 CHIEF COMPLAINT today is follow up for severe chronic paranoid schizophrenia. HISTORY OF PRESENT ILLNESS: This patient is a pleasant 50-year-old white male, established patient. He has a history of severe paranoid-type schizophrenia. He does follow closely with his mental healthcare provider and receives routine Prolixin shots every 2 weeks. He has no specific complaint today, but does describe and display a bit of anxiety over his current living condition at _____[PLACE]. He is upset over the rules he must follow there while "paying a large amount money every month." He offers no further complaints today. On EXAM today, his blood pressure is 135/96, pulse 66, respirations 18, temperature 97.3 degrees. GENERALLY the patient is quite excitable and somewhat tangential. This is unchanged. LUNGS are clear. HEART is regular without murmurs, rubs, or gallops. ABDOMEN is soft and nontender. EXTREMITIES reveal no edema. The patient did have a fasting lipid profile scheduled for today; however, he was nonfasting when he showed up for his lab draw. IMPRESSION/PLAN 1. Chronic paranoid-type schizophrenia. Patient will continue to follow up with his mental healthcare provider for receiving biweekly Prolixin injections. We will follow this along as needed. 2. Hypertension. I did start him, with his agreement, on a half tablet of Dyazide a day to help treat his

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hypertension. He has had now 2 visits in a row with elevated blood pressure and I do feel for cardio- protective effects that this is beneficial in his case. He does agree to this plan of action. We will check a basic metabolic panel when he returns to clinic. F20.0, I10, 99213, 90833 Code for the technical component. Radiology Report EXAM: Ultrasound of uterus. INDICATIONS: This is a 34-year-old female with no fetal heart motion noted on office scan. FINDINGS: By dates the patient is 8 weeks 2 days. There is a gestational sac within the endometrial cavity measuring 2.1 cm consistent with 6 weeks 4 days. There is a fetal pole measuring 7 mm, consistent with 6 weeks 4 days. There was no fetal heart motion on Doppler or on color Doppler. There is no fluid within the endometrial cavity. IMPRESSION: Gestational sac with a fetal pole but no fetal heart motion with fetal demise at 6 weeks 4 days. By dates the patient is 8 weeks 2 days. A preliminary report was called by the ultrasound technologist to the referring physician. O02.1, 76815-TC Progress Note REASON FOR VISIT: IHSS. The patient is a 51-year-old gentleman, established patient, recently diagnosed with IHSS and placed on verapamil SA 120 mg a day since past ____[DATE]. He has been doing quite well on this but says he started having upper respiratory tract symptoms last week and says he has become more short of breath. He had some greenish-yellow phlegm expectoration. No fevers or chills. He denies any chest pain. Denies syncope or palpitations. Denies PND or orthopnea. Denies bleeding, lower extremity edema, or cramps. He continues to smoke. His cholesterol status has been unknown for the last year and a half. The last one was in ____[DATE] with total cholesterol of 198, triglycerides 124, HDL 59, LDL 113. He is currently taking verapamil SA 120 mg p.o. q.d., albuterol, Paxil, multivitamins, and Flovent inhaler. Vital signs: Blood pressure 124/79, pulse 88. HEENT: PERRL. EOMI. No JVD. No carotid bruits. No pallor or icterus. LUNGS: There is wheezing bilaterally. No dullness on percussion. There are no crackles or rhonchi. CARDIOVASCULAR SYSTEM: S1, S2 are normal regular rhythm and rate, mildly on the tachycardiac side. There is a systolic ejection murmur heard at the left sternal border to the second to third intercostal space radiating across the precordium and towards the carotids. There is no gallop. ABDOMEN: Soft, nontender, and bowel sounds are present. EXTREMITIES: No clubbing, cyanosis, or edema. Pedal pulses are palpable bilaterally. ECG is consistent with 101 beats per minute sinus tachycardia, first-degree AV block, and LVH. ASSESSMENT/PLAN 1. Idiopathic hypertrophic subaortic stenosis. 2. Chronic obstructive pulmonary disease exacerbation. 3. Unknown cholesterol status. 4. Depression. 5. Tobacco dependence. RECOMMENDATIONS: I will increase his verapamil SA to 240 mg p.o. q.d. I will also follow him with an echocardiogram before he sees me next time. I would like to have a fasting lipid panel, basic metabolic panel, and thyroid panel done with his next visit and a chest x-ray today to rule out pulmonary infiltrate. I prescribed a Z-Pak, prednisone 6 day taper, and Combivent 2 puffs q.i.d. for his COPD exacerbation. I counseled him about smoking cessation and exercise. I42.1, J44.1, F32.9, F17.210, 93000

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