Practicode : Practicode Set 1-200 Final
Review Exam With 100% Correct
Answers.
RADIOLOGY REPORT Location: AAPC Family Practice
Sex: MAGE: 31DATE OF EXAM: 1/01/20XXREFERRED BY PHYSICIAN(S): M.D.PROCEDURE: X-RAY
ABDOMEN/KUB SUPINE, ONE VIEWCOMPARISON: None.I NDICATIONS: Abdomen pain. History
of stones. TECHNIQUE: A single AP supine view of the abdomen was performed.
FINDINGS:BOWEL GAS PATTERN: Normal. CALCIFICATIONS: None significant. OTHER: Normal for
age. CONCLUSION: 1. NORMAL EXAM. NO KIDNEY STONES IDENTIFIED. Electronically signed by
1/1/20XX
Case ID : OPD7029 - Answer R10.9 Unspecified abdominal pain
Z87.442 Personal history of urinary calculi
740181 Radiologic Exam Abdomen 1 View
OFFICE - ESTABLISHED Sex: FAGE 71Date: 01/01/20XXCHIEF CONCERN: She is here for follow up
of CPAP titration. PROBLEM LIST:1. A female with VVI pacemaker replacement (20XX), for
chronic atrial fibrillation with intermittent high grade A-V block and uncontrolled ventricular
rate.2. Recurrent heart failure associated with atrial fibrillation with rapid ventricular
response.3. Recurrent deep venous thrombosis with a Greenfield vena cava filter placed, on
maintenance Coumadin.4. Remote history of pulmonary embolism.5. Presyncopal episodes.6.
Partial nephrectomy for nephrolithiasis.7. Sleep apnea, using CPAP daily as required.8. History
of nonischemic cardiomyopathy, ejection fraction 45%, now 50-55%.ALLERGIES: No known drug
allergies. MEDICATIONS: Warfarin 4 mg q.d. ADDigoxin 0.125 mg q.d.Metoprolol ER 50 mg
q.d.CPAP and oxygen at nightDiltiazem 120 mg q.d.Multivitamin q.d.INTERVAL HISTORY: Since
last office visit, the pa - Answer G47.30 Sleep apnea, unspecified
R41.3 Other amnesia
Z79.01 Long term (current) use of anticoagu
99213 Office/outpatient Established Low Md
OPERATIVE REPORTAGE: 39DOS: 1/1/20XXPHYSICIAN: Carrol Andrews, MDPREOPERATIVE
DIAGNOSIS: Bilateral macromastia (hypertrophy).POSTOPERATIVE DIAGNOSIS: Bilateral
macromastia (hypertrophy).OPERATIVE PROCEDURE: Bilateral reduction mammoplasty.
SURGEON: Carrol Andrews, MDANESTHESIA: General. COMPLICATIONS: None. INDICATIONS:
Ms. Smith is a female, who presented to the clinic with symptomatic macromastia
(hypertrophy). Preauthorization was obtained to perform bilateral reduction mammoplasty.
Minimal resection was 800 g. The patient had significant macromastia where I explained that
this goal would be easily achieved. The patient agreed and wished to proceed with surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room where she was
placed in supine position. She was placed under general anesthesia. Bilateral upper extremities
,were secured to arm boards with cast padding. Both breasts were marked in - Answer N62
Hypertrophy of breast
193181 mod:50 Breast Reduction
OFFICE - ESTABLISHED SEX: FEMALEAGE: 69DOS: 1/1/20XXCHIEF COMPLAINT: Bilateral back
pain, muscle pain. HPI: Back Pain: Reported by Patient: Locations: pain radiating to the buttocks;
pain radiating to the legs. Quality: sharp. Severity: worsening; moderate (5-7). Duration: acute;
chronic; muscle spasm. Context: prior back problems; used medications for back pain; had
evaluations by back specialist. Alleviating Factors: rest; relived by changing position. Aggravating
Factors: movement/positioning; twisting; flexing back; extending back. Associated Symptoms:
no fever; no tingling; no incontinence; no shortness of breath; weak limbs; numbness of the
legs/feet. Notes: RECENT LAB REVEALED LOW POTASSIUM.PROBLEMS: None Recorded.
ALLERGIES: Allergies Not Reviewed (last reviewed 2/1/20XX). DARVON. IODINE. PENICILLINS.
MEDICATIONS: Reviewed Medications: ADVAIR DISKUSATENOLOL 100 MG
TABFENTANYLFLUTICASONEHYDROCODONE 10 MG TABLY - Answer E87.6 Hypokalemia
M51.36 Other intervertebral disc degenerative
99213 Office/outpatient Established Low Md
OFFICE VISIT - EST Sex: MAGE: 44DOS: 1/1/20XXSUBJECTIVE: The patient is a male being seen
for lumbar back pain. The symptoms have been gradual in onset with a severity of 6/10 in pain
score. This lumbar back pain is also associated with headaches. Both sides are affected equally.
He has had no history of surgery .OBJECTIVE: On exam, he has diffuse lower lumbar back pain
and headache PLAN: The patient will need a lumbar AP and lateral plain film for further
evaluation. Patient to return to office after obtaining further studies or if symptoms get worse
David Kramer, MD Electronically signed by DAVID KRAMER, MD 1/1//20XX
Case ID : OPD7206 - Answer M54.50 Low back pain, unspecified
R51.9 Headache, unspecified
SEX: MALEAGE: 75DOS: 1/1/20XXPHYSICIAN: Sidney Jones, MDPREOPERATIVE DIAGNOSIS: Left
carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome. OPERATIVE
PROCEDURE: Left endoscopic carpal tunnel release. SURGEON: Sidney Jones, MDANESTHESIA:
General. COMPLICATIONS: None. INDICATIONS: The patient a male who presented to clinic with
left hand paresthesias in the median nerve distribution. Symptoms failed to improve with
conservative management. Therefore, I recommended left endoscopic carpal tunnel release.
The patient agreed, understanding the risks of nerve injury, tendon injury, persistent symptoms,
recurrent symptoms, and need for further surgery. DESCRIPTION OF PROCEDURE: The patient
was brought to the operating room, where he was placed in a supine position. Left upper
extremity was sterilely prepped and draped in the usual fashion. Esmarch bandage was used to
exsanguinate the left upper extremi - Answer G56.02 Carpal tunnel syndrome, left upper
limb
29848 1 LT Ndsc Wrst Surg W/rls Transvrs Carpl
Emergency Department ReportSex: MAGE: 8DOB: 1/1/20xxDOS: 01/01/20XXTime Seen:
09:54Arrived- By private vehicle. Historian- mother.HISTORY OF PRESENT ILLNESSChief
,Complaint- VOMITING. This started today and is now gone. It was abrupt in onset. The
symptoms are described as moderate. He has had a subjective fever (- gone). The patient has
had vomiting and decreased oral intake. He has had abdominal pain (- gone). No diarrhea,
bloody stools, black stools, flank pain or constipation. No decreased urine output.No recent
travel. No known contact with a sick individual, history of possible bad food exposure or change
in routine. Has not recently been on antibiotics or camping. (Vomited 6x per mom, then
stopped. Now seems fine save for decrease appetite.).Similar symptoms previously: He has had
similar symptoms once previously. These were milder. (Last week for one day.).Recent medical
care: The patient was seen recently in - Answer R11.10 Vomiting, unspecified
99282 Emergency department visit for the e
OPERATIVE REPORTSEX: FEMALEAGE: 46DATE OF OPERATION: 1/1/20XXPREOPERATIVE
DIAGNOSIS: L2 WEDGE COMPRESSION FRACTURE.PROCEDURES: L2
VERTEBROPLASTY.POSTOPERATIVE DIAGNOSIS: L2 WEDGE COMPRESSION FRACTURE.SURGEON:
Christian Jones, MDANESTHESIA: GENERAL.ESTIMATED BLOOD LOSS: TWO TO THREE
DROPS.COMPLICATIONS: NONE.INDICATIONS: The patient is a middle-aged woman who several
days prior suffered a fall which she felt was a compression fracture of the L2 vertebral body. The
patient was neurologically un-compromised. She was complaining severe pain due to the
fracture and because of the presence of angulation in the fracture, my recommendation was to
perform a vertebroplasty. The procedure along with its risks, possible benefits and possible
complications were explained to the patient to her understanding. Surgical and nonsurgical
alternatives were discussed with her and her questions were answered to her satisfaction. She
conse - Answer S32.020A Wedge compression fracture of second
22511 1 Perq Vertebroplasty Uni/Bi Injection
EMERGENCY DEPARTMENTSEX: FemaleAGE: 97DOS: 1/1/20XXCHIEF COMPLAINT: Low blood
pressure per Skyler staff.HISTORY OF PRESENT ILLNESS: This is a female who was brought here
from Skyler because she was thought to have a low blood pressure and hypothermia. She
herself has had no complaints. She is in declining health, having been moved from her home to
Skyler 3 weeks ago. She has had physical and mental deterioration over the past month or so.
She is in the process of being moved into the enhanced care unit at Skyler and there was
discussion about having hospice begin providing care for her. The patient's son came to provide
more information as the patient is not able to answer questions with reliability.PAST MEDICAL
HISTORY: Significant for hypertension, arthritis, anxiety, hypothyroidism, incontinence, frequent
UTIs.MEDICATIONS:Valium.Aspirin.Potassium.Nexium.Diovan.Lasix.Armour Thyroid.ALLERGIES:
KEFLEX AND TAPE.SOCIAL - Answer R53.1 Weakness E86.0 Dehydration E87.1 Hypo-
osmolality and hyponatremia
99284 Emergency department visit for the e
Emergency Department ReportSex: FAGE: 31DOS: 01/01/20XXTime Seen: 10:44Arrived- By
private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESSChief Complaint: HEADACHE.
This started 3 days ago. It was gradual in onset. It is not gone now. Onset during cannot recall. Is
still present. It is described as pain. Described as a global headache and located in the frontal
region. No neck pain. Not located in the facial region. At its maximum, severity described as 8 /
10. When seen in the E.D., severity described as . Modifying factors: relieved by nothing.
Not worsened by anything. She has had photophobia and nausea. The patient has had vomiting
(all day for 3 days). No blurred vision, numbness or weakness.Recent medical care: (pt called Dr.
, Jones office was referred to ED). Not recently seen/assessed.REVIEW OF SYSTEMSThe patient
has had crampy, intermittent abdominal pain (2 weeks). The pain is described as locat - Answer
R51.9Headache, unspecified R10.31Right lower quadrant pain R42Dizziness and giddiness
R11.2Nausea with vomiting, unspecified
Z33.1Pregnant state, incidental
99285 Emergency department visit for the e
Age: 68Sex: MaleDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: PROLAPSE
RECTUM.PROCEDURES: REDUCTION OF PROLAPSED RECTUM UNDER
ANESTHESIA.POSTOPERATIVE DIAGNOSIS: PROLAPSE RECTUM.SURGEON: M.D.ANESTHESIA:
GENERAL VIA FACE MASK.ANESTHESIOLOGIST: RUNG-TAN AndrewsESTIMATE BLOOD LOSS:
NIL.DRAINS: NONE.IV FLUIDS: LACTATED RINGER'SCOMPLICATIONS: NONE.INDICATIONS: This is
a male with history of constipation who presented to the ED with prolapse rectum that was not
reducible by self.PROCEDURE: The patient was brought into the operating room and laid supine
on the operating table. After anesthesia was induced, the patient was placed in the lithotomy
position. A rectal exam was carried out digitally, and the anal sphincter was noted to be lax. The
prolapsed rectum was noted to be viable with no ulceration or ischemia, it was easily reduced
back into the pelvis. A small Vaseline tampon was placed in the anal canal and the bu - Answer
K62.3 Rectal prolapse
45900 1 Reduction, Procidentia (Sep Proc) Un
Emergency Department ReportSex: MAGE: 61DOS: 01/01/20XXCHIEF COMPLAINT: Left hip
pain.HISTORY OF PRESENT ILLNESS: This is a male who had been jogging ,on residential street,
today and after jogging felt as if he had some pain just superior to his left hip. He did not have
any injury. The onset was gradual. He denies any abdominal pain, nausea or vomiting. He denies
diarrhea or constipation. He denies any hematochezia or melena. He denies any other acute
complaints. He does have some complaints of some chronic pains in his joints when he uses
them more. He is right-handed and complains of some right elbow pain when he is mopping
and doing his usual activities. This has not been occurring currently or even in the last few days
but does occasionally bother him.PAST MEDICAL HISTORY: Denies.MEDICATIONS:
DeniesALLERGIES: NO KNOWN DRUG ALLERGIES.SOCIAL HISTORY: The patient denies tobacco,
alcohol or drugs. He works as a hou - Answer S39.013A Strain of muscle, fascia and tendon
M77.11 Lateral epicondylitis, right elbow
99282 Emergency department visit for the e
OFFICE - ESTABLISHEDSEX: FemaleAGE: 67Date: 01/01/20XXCHIEF CONCERN: She is here for
four-month checkup.PROBLEM LIST:1. Hypertension, adequately controlled on present
medications.2. Abnormal EKG.3. Hyperlipidemia.ALLERGIES: Sulfa (nausea and vomiting),
simvastatin (agitation).MEDICATIONSCardizem CD 240 mg q.d.Lisinopril 40 mg a.m. and 20 mg
p.m.Lorazepam 1 mg b.i.d.Fenofibrate 160 mg h.s.Omega 3 fish oil q.d.Calcium 1000 mg
q.d.Vitamin D3 400Move FreeTylenol Arthritis h.s.Metoprolol ER 50 mg q.d.INTERVAL
HISTORY:Following complaints of increasing lower extremity edema, diltiazem was decreased
and beta blocker was added. Overall, she feels quite well. Home blood pressures are now
120/80 to 138/89, pulse 69 to 80. She is having no significant side effects. Last month, she was
treated as an outpatient for bronchitis, which has now completely resolved and she feels
Review Exam With 100% Correct
Answers.
RADIOLOGY REPORT Location: AAPC Family Practice
Sex: MAGE: 31DATE OF EXAM: 1/01/20XXREFERRED BY PHYSICIAN(S): M.D.PROCEDURE: X-RAY
ABDOMEN/KUB SUPINE, ONE VIEWCOMPARISON: None.I NDICATIONS: Abdomen pain. History
of stones. TECHNIQUE: A single AP supine view of the abdomen was performed.
FINDINGS:BOWEL GAS PATTERN: Normal. CALCIFICATIONS: None significant. OTHER: Normal for
age. CONCLUSION: 1. NORMAL EXAM. NO KIDNEY STONES IDENTIFIED. Electronically signed by
1/1/20XX
Case ID : OPD7029 - Answer R10.9 Unspecified abdominal pain
Z87.442 Personal history of urinary calculi
740181 Radiologic Exam Abdomen 1 View
OFFICE - ESTABLISHED Sex: FAGE 71Date: 01/01/20XXCHIEF CONCERN: She is here for follow up
of CPAP titration. PROBLEM LIST:1. A female with VVI pacemaker replacement (20XX), for
chronic atrial fibrillation with intermittent high grade A-V block and uncontrolled ventricular
rate.2. Recurrent heart failure associated with atrial fibrillation with rapid ventricular
response.3. Recurrent deep venous thrombosis with a Greenfield vena cava filter placed, on
maintenance Coumadin.4. Remote history of pulmonary embolism.5. Presyncopal episodes.6.
Partial nephrectomy for nephrolithiasis.7. Sleep apnea, using CPAP daily as required.8. History
of nonischemic cardiomyopathy, ejection fraction 45%, now 50-55%.ALLERGIES: No known drug
allergies. MEDICATIONS: Warfarin 4 mg q.d. ADDigoxin 0.125 mg q.d.Metoprolol ER 50 mg
q.d.CPAP and oxygen at nightDiltiazem 120 mg q.d.Multivitamin q.d.INTERVAL HISTORY: Since
last office visit, the pa - Answer G47.30 Sleep apnea, unspecified
R41.3 Other amnesia
Z79.01 Long term (current) use of anticoagu
99213 Office/outpatient Established Low Md
OPERATIVE REPORTAGE: 39DOS: 1/1/20XXPHYSICIAN: Carrol Andrews, MDPREOPERATIVE
DIAGNOSIS: Bilateral macromastia (hypertrophy).POSTOPERATIVE DIAGNOSIS: Bilateral
macromastia (hypertrophy).OPERATIVE PROCEDURE: Bilateral reduction mammoplasty.
SURGEON: Carrol Andrews, MDANESTHESIA: General. COMPLICATIONS: None. INDICATIONS:
Ms. Smith is a female, who presented to the clinic with symptomatic macromastia
(hypertrophy). Preauthorization was obtained to perform bilateral reduction mammoplasty.
Minimal resection was 800 g. The patient had significant macromastia where I explained that
this goal would be easily achieved. The patient agreed and wished to proceed with surgery.
DESCRIPTION OF PROCEDURE: The patient was brought to the operating room where she was
placed in supine position. She was placed under general anesthesia. Bilateral upper extremities
,were secured to arm boards with cast padding. Both breasts were marked in - Answer N62
Hypertrophy of breast
193181 mod:50 Breast Reduction
OFFICE - ESTABLISHED SEX: FEMALEAGE: 69DOS: 1/1/20XXCHIEF COMPLAINT: Bilateral back
pain, muscle pain. HPI: Back Pain: Reported by Patient: Locations: pain radiating to the buttocks;
pain radiating to the legs. Quality: sharp. Severity: worsening; moderate (5-7). Duration: acute;
chronic; muscle spasm. Context: prior back problems; used medications for back pain; had
evaluations by back specialist. Alleviating Factors: rest; relived by changing position. Aggravating
Factors: movement/positioning; twisting; flexing back; extending back. Associated Symptoms:
no fever; no tingling; no incontinence; no shortness of breath; weak limbs; numbness of the
legs/feet. Notes: RECENT LAB REVEALED LOW POTASSIUM.PROBLEMS: None Recorded.
ALLERGIES: Allergies Not Reviewed (last reviewed 2/1/20XX). DARVON. IODINE. PENICILLINS.
MEDICATIONS: Reviewed Medications: ADVAIR DISKUSATENOLOL 100 MG
TABFENTANYLFLUTICASONEHYDROCODONE 10 MG TABLY - Answer E87.6 Hypokalemia
M51.36 Other intervertebral disc degenerative
99213 Office/outpatient Established Low Md
OFFICE VISIT - EST Sex: MAGE: 44DOS: 1/1/20XXSUBJECTIVE: The patient is a male being seen
for lumbar back pain. The symptoms have been gradual in onset with a severity of 6/10 in pain
score. This lumbar back pain is also associated with headaches. Both sides are affected equally.
He has had no history of surgery .OBJECTIVE: On exam, he has diffuse lower lumbar back pain
and headache PLAN: The patient will need a lumbar AP and lateral plain film for further
evaluation. Patient to return to office after obtaining further studies or if symptoms get worse
David Kramer, MD Electronically signed by DAVID KRAMER, MD 1/1//20XX
Case ID : OPD7206 - Answer M54.50 Low back pain, unspecified
R51.9 Headache, unspecified
SEX: MALEAGE: 75DOS: 1/1/20XXPHYSICIAN: Sidney Jones, MDPREOPERATIVE DIAGNOSIS: Left
carpal tunnel syndrome. POSTOPERATIVE DIAGNOSIS: Left carpal tunnel syndrome. OPERATIVE
PROCEDURE: Left endoscopic carpal tunnel release. SURGEON: Sidney Jones, MDANESTHESIA:
General. COMPLICATIONS: None. INDICATIONS: The patient a male who presented to clinic with
left hand paresthesias in the median nerve distribution. Symptoms failed to improve with
conservative management. Therefore, I recommended left endoscopic carpal tunnel release.
The patient agreed, understanding the risks of nerve injury, tendon injury, persistent symptoms,
recurrent symptoms, and need for further surgery. DESCRIPTION OF PROCEDURE: The patient
was brought to the operating room, where he was placed in a supine position. Left upper
extremity was sterilely prepped and draped in the usual fashion. Esmarch bandage was used to
exsanguinate the left upper extremi - Answer G56.02 Carpal tunnel syndrome, left upper
limb
29848 1 LT Ndsc Wrst Surg W/rls Transvrs Carpl
Emergency Department ReportSex: MAGE: 8DOB: 1/1/20xxDOS: 01/01/20XXTime Seen:
09:54Arrived- By private vehicle. Historian- mother.HISTORY OF PRESENT ILLNESSChief
,Complaint- VOMITING. This started today and is now gone. It was abrupt in onset. The
symptoms are described as moderate. He has had a subjective fever (- gone). The patient has
had vomiting and decreased oral intake. He has had abdominal pain (- gone). No diarrhea,
bloody stools, black stools, flank pain or constipation. No decreased urine output.No recent
travel. No known contact with a sick individual, history of possible bad food exposure or change
in routine. Has not recently been on antibiotics or camping. (Vomited 6x per mom, then
stopped. Now seems fine save for decrease appetite.).Similar symptoms previously: He has had
similar symptoms once previously. These were milder. (Last week for one day.).Recent medical
care: The patient was seen recently in - Answer R11.10 Vomiting, unspecified
99282 Emergency department visit for the e
OPERATIVE REPORTSEX: FEMALEAGE: 46DATE OF OPERATION: 1/1/20XXPREOPERATIVE
DIAGNOSIS: L2 WEDGE COMPRESSION FRACTURE.PROCEDURES: L2
VERTEBROPLASTY.POSTOPERATIVE DIAGNOSIS: L2 WEDGE COMPRESSION FRACTURE.SURGEON:
Christian Jones, MDANESTHESIA: GENERAL.ESTIMATED BLOOD LOSS: TWO TO THREE
DROPS.COMPLICATIONS: NONE.INDICATIONS: The patient is a middle-aged woman who several
days prior suffered a fall which she felt was a compression fracture of the L2 vertebral body. The
patient was neurologically un-compromised. She was complaining severe pain due to the
fracture and because of the presence of angulation in the fracture, my recommendation was to
perform a vertebroplasty. The procedure along with its risks, possible benefits and possible
complications were explained to the patient to her understanding. Surgical and nonsurgical
alternatives were discussed with her and her questions were answered to her satisfaction. She
conse - Answer S32.020A Wedge compression fracture of second
22511 1 Perq Vertebroplasty Uni/Bi Injection
EMERGENCY DEPARTMENTSEX: FemaleAGE: 97DOS: 1/1/20XXCHIEF COMPLAINT: Low blood
pressure per Skyler staff.HISTORY OF PRESENT ILLNESS: This is a female who was brought here
from Skyler because she was thought to have a low blood pressure and hypothermia. She
herself has had no complaints. She is in declining health, having been moved from her home to
Skyler 3 weeks ago. She has had physical and mental deterioration over the past month or so.
She is in the process of being moved into the enhanced care unit at Skyler and there was
discussion about having hospice begin providing care for her. The patient's son came to provide
more information as the patient is not able to answer questions with reliability.PAST MEDICAL
HISTORY: Significant for hypertension, arthritis, anxiety, hypothyroidism, incontinence, frequent
UTIs.MEDICATIONS:Valium.Aspirin.Potassium.Nexium.Diovan.Lasix.Armour Thyroid.ALLERGIES:
KEFLEX AND TAPE.SOCIAL - Answer R53.1 Weakness E86.0 Dehydration E87.1 Hypo-
osmolality and hyponatremia
99284 Emergency department visit for the e
Emergency Department ReportSex: FAGE: 31DOS: 01/01/20XXTime Seen: 10:44Arrived- By
private vehicle. Historian- patient.HISTORY OF PRESENT ILLNESSChief Complaint: HEADACHE.
This started 3 days ago. It was gradual in onset. It is not gone now. Onset during cannot recall. Is
still present. It is described as pain. Described as a global headache and located in the frontal
region. No neck pain. Not located in the facial region. At its maximum, severity described as 8 /
10. When seen in the E.D., severity described as . Modifying factors: relieved by nothing.
Not worsened by anything. She has had photophobia and nausea. The patient has had vomiting
(all day for 3 days). No blurred vision, numbness or weakness.Recent medical care: (pt called Dr.
, Jones office was referred to ED). Not recently seen/assessed.REVIEW OF SYSTEMSThe patient
has had crampy, intermittent abdominal pain (2 weeks). The pain is described as locat - Answer
R51.9Headache, unspecified R10.31Right lower quadrant pain R42Dizziness and giddiness
R11.2Nausea with vomiting, unspecified
Z33.1Pregnant state, incidental
99285 Emergency department visit for the e
Age: 68Sex: MaleDATE OF OPERATION: 1/1/20XXPREOPERATIVE DIAGNOSIS: PROLAPSE
RECTUM.PROCEDURES: REDUCTION OF PROLAPSED RECTUM UNDER
ANESTHESIA.POSTOPERATIVE DIAGNOSIS: PROLAPSE RECTUM.SURGEON: M.D.ANESTHESIA:
GENERAL VIA FACE MASK.ANESTHESIOLOGIST: RUNG-TAN AndrewsESTIMATE BLOOD LOSS:
NIL.DRAINS: NONE.IV FLUIDS: LACTATED RINGER'SCOMPLICATIONS: NONE.INDICATIONS: This is
a male with history of constipation who presented to the ED with prolapse rectum that was not
reducible by self.PROCEDURE: The patient was brought into the operating room and laid supine
on the operating table. After anesthesia was induced, the patient was placed in the lithotomy
position. A rectal exam was carried out digitally, and the anal sphincter was noted to be lax. The
prolapsed rectum was noted to be viable with no ulceration or ischemia, it was easily reduced
back into the pelvis. A small Vaseline tampon was placed in the anal canal and the bu - Answer
K62.3 Rectal prolapse
45900 1 Reduction, Procidentia (Sep Proc) Un
Emergency Department ReportSex: MAGE: 61DOS: 01/01/20XXCHIEF COMPLAINT: Left hip
pain.HISTORY OF PRESENT ILLNESS: This is a male who had been jogging ,on residential street,
today and after jogging felt as if he had some pain just superior to his left hip. He did not have
any injury. The onset was gradual. He denies any abdominal pain, nausea or vomiting. He denies
diarrhea or constipation. He denies any hematochezia or melena. He denies any other acute
complaints. He does have some complaints of some chronic pains in his joints when he uses
them more. He is right-handed and complains of some right elbow pain when he is mopping
and doing his usual activities. This has not been occurring currently or even in the last few days
but does occasionally bother him.PAST MEDICAL HISTORY: Denies.MEDICATIONS:
DeniesALLERGIES: NO KNOWN DRUG ALLERGIES.SOCIAL HISTORY: The patient denies tobacco,
alcohol or drugs. He works as a hou - Answer S39.013A Strain of muscle, fascia and tendon
M77.11 Lateral epicondylitis, right elbow
99282 Emergency department visit for the e
OFFICE - ESTABLISHEDSEX: FemaleAGE: 67Date: 01/01/20XXCHIEF CONCERN: She is here for
four-month checkup.PROBLEM LIST:1. Hypertension, adequately controlled on present
medications.2. Abnormal EKG.3. Hyperlipidemia.ALLERGIES: Sulfa (nausea and vomiting),
simvastatin (agitation).MEDICATIONSCardizem CD 240 mg q.d.Lisinopril 40 mg a.m. and 20 mg
p.m.Lorazepam 1 mg b.i.d.Fenofibrate 160 mg h.s.Omega 3 fish oil q.d.Calcium 1000 mg
q.d.Vitamin D3 400Move FreeTylenol Arthritis h.s.Metoprolol ER 50 mg q.d.INTERVAL
HISTORY:Following complaints of increasing lower extremity edema, diltiazem was decreased
and beta blocker was added. Overall, she feels quite well. Home blood pressures are now
120/80 to 138/89, pulse 69 to 80. She is having no significant side effects. Last month, she was
treated as an outpatient for bronchitis, which has now completely resolved and she feels
