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GRADED QUIZ 11: From the health record of a patient seen in the emergency room/observation area for an allergic reaction:Discharge SummaryDate of Discharge: 01/08/XXChief Complaint: Allergic reaction to Bactrim, resulting in angioedema and mild respiratory distress.Hospital Course: Fifty-six-year-old male admitted for angioedema after taking Bactrim for an ear infection. The patient had mild respiratory distress and marked swelling of his hands, face, and his oropharynx. The patient was given IV steroids in the Emergency Room and was admitted overnight for observation. The patient's swelling rapidly improved and by the morning after his admission he was back to baseline. He had no complaints of shortness of breath and desired to go home.Condition on Discharge: Good. Activity: As tolerated. Diet: As tolerated.Medications: Home medications only including:1. Celebrex 200 mg one b.i.d.2. Isosorbide 30 mg once a day.3. Atenolol 25 mg per day.4. Lipitor 10 mg per day.Follow-Up: Will be as needed with primary care physician if ear problem returns and/or respiratory distress.Emergency AssessmentChief Complaint: Swelling, itching, and change in voice.Present Illness:? This is a 56-year-old white male with a history of allergic reaction to an antibiotic in the past, who presents today after taking his second dose of Bactrim this morning at home. He then had acute onset of swelling, redness, itching, and change in voice; also states that he was slightly short of breath but no wheezing. He denies any nausea, vomiting, fevers, chills.Past Medical History: Coronary arter disease, MI 2 years ago, is currently take Celebrex, Isosorbide, Atenolol, Lipitor, and Bactrim that he just started on his morning.Physical Examination:? Appears very red, swollen diffusely with erythematous rash, macular type rash. Blood pressure is 145/77, heart rate of 120, respiration rate 18 and 02; saturation is 96%. On room air. HEENT: He does have swollen eyelids, both upper and lower eyelids, with also some facial swelling and some uvular swelling as well as some lateral pharyngeal and uvualr swelling, which appears to be allergic in nature. His tongue appears also slightly swollen, does not have any neck swelling, also has an erythematous rash. Lungs: Clear to auscultation with no wheezing noted. Abdomen: Soft, nontender.Ed Course: Received Benadryl 25 mg IV, Pepcid 20 mg IV, Solu-Medrol 125 mg IV. At this point, his voice was still changing, and decision was made to admit the patient to the hospital for observation and then to observe and given a second dose of Solu-Medrol and Benadryl. Consultation between patient's private physician.Select the correct codes for this observation patient.a. 961.0, 786.09, 995.1, 693.0, E857, E849.0b. 995.20, E931.0, E849.0c. 995.1, 786.09, E931.0, E849.0d. 995.1, 786.09, 693.0, E930.9, E849.02: Operative Report Preoperative Diagnosis: Circular saw injury with complex laceration of left index finger withlacerationof extensor tendon and join capsule; laceration collateral ligament, radial side; displaced fracture at base of the middle phalanx, articular invovement. Postoperative Diagnosis: Circular saw injury with complex laceration of left index finger iwth laceration collateral ligament, radial side; compound fracture, base of the middle phalanx, articular involvement. Operative Performed Debridement and repair extensor tendon and joint capsule. Repair radial collateral ligament and wound closure.?Anesthesia: Digital blockThis is a 42-year-old white male who accidentally injured his left index finger on a circular saw while workingon broken shutters at home in his garage. The patient sustained a jagged laceration over the dorsal radial aspect of the index finger at the proximal interphalangeal joint. The wound was deep, involving the joint capsule, extensor tendon, and collateral ligament. The bone was also involved, especially at the base of the middle phalanx into the apical surface. The sensation to the tip of the finger was intact, especially all of the radial side. The wound measured about 3 cm in lenght. Procedure: 0.5 percent Marcaine was used as local anesthetic digital block. After anesthesia had been obtained, the hand was prepped and draped int he usual manner. Tourniquet then was placed at the base of the fingers. The wound was then debrided. The minute loose bone and articular surface had to be removed. Some skin debrided. The minute loose bone and articular surface had to be removed. Some skin debrided also was removed. After satisfactory debridement, the joint capsule and extensor tendon then were repaired with 5-0 PDS?suture material. The skin then was carefully approximated with 5-0 nylon. After completion, a dressing was applied. The tourniquet was released and there was good perfusion throughout the fingers. An aluminum splint was placed. The patient received 1 g of Ancef in the emergency room. He will continue to take Keftab 500 mg twice daily for 4 days and Vicodin 1 tablet q.4h p.r.n. for pain. The postoperative instructions were given. Also the patient was informed about his injury and complications, especially wound infection and some stiffness of the finger. The patient will be followed up in my office. I need One (1) diagnosis code; Two (2) E codes; Three (3) CPT codes Graded quiz 21: 75 year old female admitted because of chronic diarrhea and dehydration. History of herpes zoster, right upper extremity, leading to monoparesis, right upper extremity with postherpetic neuralgia on the right side of the chest. She has been treated with heavy doses of Neurontin with no significant relief. On admission her chest xray showed resolving lingular and left lower lobe pneumonia in the right perihilar region. The patient is being treated with levaquin. She has colonoscopy in the hospital for her iron deficiency anemia. Colonoscopy with biopsies taken of the small bowel as well as the rectosigmoid area showed no specific etiology. I need Seven (7) diagnosis codes; One (1) procedure code2: The patient, a 55-year-old female, was admitted with diabetic gastroparesis documented as due to steroid-induced diabetes. The patient is on long-term use of systemic corticosteroids, which are properly taken. I need Two (2) diagnosis codes; One (1) V code; One (1) E code3: The following information was contained in the health record:4. Chief Complaint: History of nausea with severe vomiting for the past 2 to 3 days. Diabetes mellitus diagnosed at the patient was 12 years.Hospital Course: This 31 year old male patient has a history of Type I diabetes mellitus and is on 15 units NPH and 10 of regular in the morning and 10 units of NPH and 5 regular in the evening. The patient started having symptoms of nausea. The patient at the same time had increased frequency of urination and polydipsia. The patient was dehydrated upon admission. There was no evidence of thrombophlebitis, varicosities, or edema on examination of the extremities. The patient was hydrated, and as a result, the blood sugar decreased from more than 600 to normal levels. The patient was discharged with the diagnosis of diabetic ketoacidosis, type I. I need Two (2) diagnosis codes5: from the health record of a patient requiring thyroid surgery. History: patient is 50 year old female who noted a swelling in the neck. Outpatient workup was done. Thyroid scan and thyroid sonogram revealed moderate enlargement of the left lobe of the thyroid gland measuring 1.1 x 2.2 cm, a solid nodule at the anterior aspect of the mid of the left lobe of thyroid measuring approximately 1 x 1.9 cm, a small cyst in the middle of the left lobe of the thyroid measuring 2.4 cm, normal right lobe measuring 2.3 mm. thyroid scan showed hot nodule, which is usually negative for malignancy. The fine needle aspiration was strongly suspicious for papillary carcinoma.IMPRESSION: Papillary carcinoma of the thyroid REPORT OF OPERATION Preoperative Diagnosis: Steroid nodule left lobe, rule out papillary carcinoma Postoperative Diagnosis: Papillary carcinoma of thyroid Procedure: Left thyroid lobectomy with isthmectomy and frozen section. Subsequently, patient underwent total thyroid lobectomy. Anesthesia: general endotrachealEstimated blood loss: 50 cc. replacement; IV fluids, sponge count, needle count times two correct.Technique: after a patient was well anesthetized with general endotracheal anesthesia, a sand bag was placed underneath the shoulder blades. The neck was extended and stabilized and placed on a foam head pillow. Entire neck and anterior chest was prepped and draped in the usual manner. The skin incision site was marked with 2-0 VICRYL suture with pressure. Preempt analgesia was obtained with infiltration of .25 percent Marcaine. Transverse skin incision was made in the anterior part of the neck, which was deepened through the subcutaneous tissue and the platysma. Upper and lower flaps were raised, upper flap up to the thyroid cartilage, lower flap up to the sternal notch. Hemostasis obtained with cautery as well as 3-0NvicryL sutures. Midline fascia was incised. Strap muscles on the left side were separated from the underlying thyroid gland. Strap muscles were retracted laterally with a green retractor. Middle thyroid veins were identified, divided between the clamps, ligated with 3-0 VICRYL suture. Patientwas noted to have palpable thyroid nodule on the left lower part of the thyroid gland. Superior thyroid vessels were identified. External of the superior laryngeal nerve was identified and protected. Superior thyroid vessels were divided close to the thyroid clamp between the mixter clamps and ligated with 2-0 VICRYL suture. Recurrent laryngeal nerve was identified and protected throughout the procedure. Superior and inferior parathyroids were identified, protected with their vasculature. Inferior thyroid vessels were divided close to the thyroid capsule after it branching to preserve the blood supply to the parathyroid gland. Isthmus was divided between the clamps and the entire thyroid lobe was removed and sent for frozen section, which was reported to be a papillary carcinoma. After the pathology report, the decision was made to proceed with the total thyroidectomy, which was carried out in the following manner: strap muscles on the right side were separated from the right thyroid gland. Middle thyroid vessels were divided between the clamps, ligated with 3-0 VICRYL suture. Superior and inferior thyroid poles were identified. Superior thyroid vessels were divided close to the upper pole. During the procedure, the external branch of the superior laryngeal nerve was identified and protected. The divided vessel was ligated with 2-0 VICRYL suture. Recurrent laryngeal nerve was identified and protected. Inferior and superior parathyroid glands were identified and protected with vasculature. Inferior thyroid vessel branches were divided between the clamps; thereby the blood supply to the parathyroid was preserved. Care was taken to protect the recurrent laryngeal nerve throughout the procedure. The right lobe of the thyroid was completely removed after satisfactory hemostasis. No drains were placed. The strap muscle was approximated with interrupted 3-0 VICRYL suture. Platysma and subcutaneous tissue was approximated with interrupted 4-0 VICRYL suture. Skin approximated with subcuticular 4- Dexon. Sterile dressing was applied. At the end of the procedure the vocal cords were inspected. They were moving equally well. The patient tolerated the entire procedure well and was discharged in stable condition to the recovery room. Discharge information: patient discharged after 2 days, with no complication. Diagnosis: Papillary carcinoma of the thyroid, left and right lobes, with follicular pattern. Papillary carcinoma positive in one cervical lymph node. I need two (2) diagnosis codes; One (1) procedure code 6: The discharge diagnosis is urosepsis due to streptococcus. On admission the patient’s white blood count was 15,000. Urine culture and blood cultures were both positive for streptococcus. After querying the physician regarding the meaning of urosepsis, an addendum was added to the patient’s medical record: Streptococcal B sepsis and urinary tract infection also due to streptococcus B I need 4 diagnosis codes.7: This 23 year old female is admitted with pneumonia. She also has multiple bilateral lesions of the vulva and vagina with fluid filled blisters. The history includes fever and pain for 2 days. Sputum cultures show group A streptococcus. History also includes pain, particularly with urination and itching of the genitals. Physician documents group A streptococcus pneumonia and vulvovaginitis due therpes. ................
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