Specialty Code Set Training Family Practiceaapcperfect.s3.amazonaws.com/3f227f64-019f-488a-b5... · Specialty Code Set Training. Family Practice. ... downwardly adjusting her insulins,

ICD-10-CMSpecialty Code Set Training

Family Practice2014

Module 5

ii ICD-10-CM Specialty Code Set Training — Family Practice © 2013 AAPC. All rights reserved.052813

DisclaimerThis course was current at the time it was published. This course was prepared as a tool to assist the participant in understanding how to prepare for ICD-10-CM. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility of the use of this information lies with the student. AAPC does not accept responsibility or liability with regard to errors, omissions, misuse, and misinterpretation. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free and will bear no responsibility, or liability for the results or consequences of the use of this course.

AAPC does not accept responsibility or liability for any adverse outcome from using this study program for any reason including undetected inaccuracy, opinion, and analysis that might prove erroneous or amended, or the coder’s misunderstanding or misapplication of topics. Application of the information in this text does not imply or guarantee claims payment. Inquiries of your local carrier(s)’ bulletins, policy announcements, etc., should be made to resolve local billing requirements. Payers’ interpretations may vary from those in this program. Finally, the law, applicable regulations, payers’ instructions, interpretations, enforcement, etc., may change at any time in any particular area.

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Clinical Examples Used in this BookAAPC believes it is important in training and testing to reflect as accurate a coding setting as possible to students and examinees. All examples and case studies used in our study guides and exams are actual, redacted office visit and procedure notes donated by AAPC members.

To preserve the real world quality of these notes for educational purposes, we have not re-written or edited the notes to the stringent grammatical or stylistic standards found in the text of our products. Some minor changes have been made for clarity or to correct spelling errors originally in the notes, but essentially they are as one would find them in a coding setting.

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© 2013 AAPC. All rights reserved. www.aapc.com iii052813

ICD-10 ExpertsRhonda Buckholtz, CPC, CPMA, CPC-I, CGSC, CPEDC, CENTC, COBGC VP, ICD-10 Training and Education

Shelly Cronin, CPC, CPMA, CPC-I, CANPC, CGSC, CGIC, CPPM Director, ICD-10 Training

Betty Hovey, CPC, CPMA, CPC-I, CPC-H, CPB, CPCD Director, ICD-10 Development and Training

Jackie Stack, CPC, CPB, CPC-I, CEMC, CFPC, CIMC, CPEDC Director, ICD-10 Development and Training

Peggy Stilley, CPC, CPB, CPMA, CPC-I, COBGC

Director, ICD-10 Development and Training

Contents

Coding Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

© 2013 AAPC. All rights reserved. www.aapc.com 59052813

Case Studies

Case 1Subjective: Patient comes in today for ongoing issues around her diabetic control. We have been fairly aggressive, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night as well as her sliding scale Humalog insulin prior to meals. Despite frequent decreases in her insulin regimen, she continues to have somewhat low blood glucoses, most notably in the morning when the glucoses have been in the 70s despite decreasing her Lantus insulin from around 84 units down to 60 units, which is a considerable change. What I cannot explain is why her glucoses have not really climbed at all despite the decrease in insulin. The staff reports to me that her appetite is good and that she is eating as well as ever. I talked to Anna today. She feels a little fatigued. Otherwise, she is doing well.

Physical Examination: Vitals as in the chart. The patient is a pleasant and cooperative. She is in no apparent distress.

Assessment and Plan: Diabetes, still with some problematic low blood glucoses, most notably in the morning. To address this situation, I am going to hold her Lantus insulin tonight and decrease and then change the administration time to in the morning. She will get 55 units in the morning. I am also decreasing once again her Humalog sliding scale insulin prior to meals. I will review the blood glucoses again next week.

ICD-10-CM code(s): ________________________________________

Case 2Subjective: The patient is a 66-year-old female who presents to the clinic today for a five-month recheck on her type II diabetes mellitus, as well as mixed hyperlipidemia. As far as her diabetes she states that she only checks her blood sugars in the morning and those have all been ranging less than 100. She has not been checking any two hours after meals. Her blood pressures when she does check them have been running normal as well but she does not have any record of these present with her. No other issues or concerns.

Medications: She is on Hyzaar 50/12.5 one-half p.o. daily, coated aspirin daily, lovastatin 40 mg one-half tab p.o. daily, multivitamin daily, metformin 500 mg one tab p.o. b.i.d.; however, she has been skipping her second dose during the day.

Social History: She is a nonsmoker.

Objective: Vital Signs: Temperature: 98.2. Pulse: 64. Respirations: 16. Blood pressure: 110/56. Weight: 169.

General: Alert and oriented x 3. No acute distress noted.

Neck: No lymphadenopathy, thyromegaly, JVD or bruits.

60 ICD-10-CM Specialty Code Set Training — Family Practice © 2013 AAPC. All rights reserved.052813

Case Studies

Lungs: Clear to auscultation.

Heart: Regular rate and rhythm without murmur or gallops present.

Musculoskeletal: She did have full range of motion of her shoulders. There is no swelling, crepitus or discoloration noted.

Medical Decision Making: Most recent hemoglobin A1c was 5.6% back in October 2004. Most recent lipid checks were obtained back in July 2004. We have not had this checked since that time.

Assessment: 1. Type II diabetes mellitus.2. Mixed hyperlipidemia.

Plan: 1. She is going to go to lab to obtain a hemoglobin A1c, BMP, lipids, CPK, liver enzymes and quantitative microalbumin.

ICD-10-CM code(s): ________________________________________

Case 3Subjective: This is a 21-year-old young man who comes in with about 10 days worth of sinus congestion. He does have significant allergies for ragweed pollen. The drainage has been clear. He had a little bit of a headache yesterday. He has had no fever. No one else is ill at home . Patient still smokes one pack of cigarettes per day.

Current Medications: Allegra. He has been taking this regularly. He is not sure the Allegra is working for him anymore. He does think it works better than Claritin, though.

Physical Exam:General: Alert young man in no distress.

HEENT: TMs clear and mobile. Pharynx clear. Mouth moist. Nasal mucosa pale with clear discharge.

Neck: Supple without adenopathy.

Heart: Regular rate and rhythm without murmur.

Lungs: Lungs clear, no tachypnea, wheezing, rales or retractions.

Abdomen: Soft, nontender, without masses or splenomegaly.

Assessment: Allergic rhinitis. Tobacco dependence.

Plan: Change to Zyrtec 10 mg samples were given. He is not using nasal spray, but he has some at home. He should restart this. Call if any further problems.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 4Chief Complaint: Cough and abdominal pain for two days.

History of Present Illness: This is a 76-year-old female who has a history of previous pneumonia, who presented with generalized body aches, cough, nausea, and right-sided abdominal pain for two days. The patient stated that the abdominal pain was only associated with coughing. The patient reported that the cough is dry in nature and the patient had subjective fevers and chills at home.

Allergies: THE PATIENT HAS NO KNOWN DRUG ALLERGIES.

Social History: The patient quit smoking 17 years ago; prior to that had smoked one pack of cigarettes per day for 44 years. Denies any alcohol use. Denies any IV drug use.

Physical Examination: GENERAL: This is a 76-year-old female, well nourished. VITAL SIGNS: On presentation included a temperature of 100.1, pulse of 144 with a blood pressure of 126/77, the patient is saturating at 95% on room air, and has respiratory rate of 20. HEENT: Anicteric sclerae. Conjunctivae pink. Throat was clear. Mucosal membranes were dry. CHEST: Coarse breath sounds bilaterally at the bases. CARDIAC: S1 and S2. No murmurs, rubs or gallops. No evidence of carotid bruits. ABDOMEN: Positive bowel sounds, presence of soreness on examination in the abdomen on palpation. There is no rebound or guarding. EXTREMITIES: No clubbing, cyanosis or edema.

Hospital Course: The patient had a chest X-ray, which showed increased markings present bilaterally likely consistent with chronic lung changes. There is no evidence of effusion or consolidation. Degenerative changes were seen in the shoulder. The patient also had an abdominal X-ray, which showed nonspecific bowel gas pattern. Urinalysis showed no evidence of infection, but parainfluenza was positive. Preliminary blood cultures have been with no growth to date status post 48 hours. The patient was started on cefepime 1 g IV q.12h. and given IV hydration. She has also been on Xopenex nebs q.8h. round the clock and in regards to her hypertension, she was continued on her hydrochlorothiazide and propranolol. She received Lovenox subcutaneously for DVT prophylaxis. Today, she feels much improved with still only a mild cough. The patient has been afebrile for two days, saturating at 97% on room air with a respiratory rate of 18. Her white count on presentation was 13.6 and yesterday’s white count was 10.3.

Final Diagnosis: Acute bronchitis due to parainfluenza virus.

Disposition: The patient will be going home.

Medications: Propranolol 40 mg p.o. daily. Also, Avelox 400 mg p.o. daily x10 days, guaifenesin 10 cc p.o. q.6h. p.r.n. for cough, and aspirin 81 mg p.o. daily.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 5Chief Complaint: Diarrhea, vomiting, and generalized abdominal pain.

History of Present Illness: The patient is an 85-year-old female who presents with a chief complaint as described above. The patient is a very poor historian and is extremely hard of hearing, and therefore, very little history is available. She was found by her granddaughter sitting on the toilet having diarrhea, and apparently had also just vomited. Upon my questioning of the patient, she can confirm that she has been sick to her stomach and has vomited. She cannot tell me how many times. She is also unable to describe the vomitus. She also tells me that her belly has been hurting. I am unable to get any further history from the patient because, again, she is an extremely poor historian and very hard of hearing.

Family History: Unknown.

Social History: Also unknown.

Review of Systems: Unobtainable secondary to the patient’s condition.

Physical Examination:VITAL SIGNS: Pulse 80. Respiratory rate 18. Blood pressure 130/80. Temperature 97.6.

GENERAL: Elderly black female who is uncomfortable.

NECK: No JVD. No thyromegaly.

EARS, NOSE, AND THROAT: Her oropharynx is dry. Her hearing is very diminished.

CARDIOVASCULAR: Regular rhythm. No lower extremity edema.

GI: Mild epigastric tenderness to palpation without guarding or rebound. Bowel sounds are normoactive. RESPIRATORY: Clear to auscultation bilaterally with a normal effort.

SKIN: Warm, dry, no erythema.

NEUROLOGICAL: The patient attempts to answer questions when asked, but is very hard of hearing. She is seen to move all extremities spontaneously.

Diagnostic Data: White count 9.6, hemoglobin 15.9, hematocrit 48.2, platelet count 345, PTT 24, PT 13.3, INR 0.99, sodium 135, potassium 3.3, chloride 95, bicarb 20, BUN 54, creatinine 2.2, glucose 165, calcium 10.3, magnesium 2.5, total protein 8.2, albumin 3.8, AST 33, ALT 26, alkaline phosphatase 92. Cardiac isoenzymes negative x1. EKG shows sinus rhythm with a rate of 96 and a prolonged QT interval.

Assessment and Plan:

Epigastric abdominal pain, diarrhea and vomiting. Will check stool studies, white count, hemoglobin, BUN & creatinine. Will call patient’s family with results.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 6Chief Complaint: Chest pain. Palpitations.

HPI: A 49-year-old man is evaluated for severe left precordial chest pain. The pain is sharp in quality and worsens with cough or deep breathing. The chest pain has waxed and waned for the last 3 days and was preceded by a 3-day history of nonproductive cough, chills, myalgias, and fatigue. He smokes 2 packs of cigarettes per day for the past 29 years. He has hypertension which has not been well controlled for the past year. His medications include lisinopril and low-dose aspirin.

Palpitations History: Palpitations—frequent, 2 x per week. No caffeine, no ETOH. + stress. No change with Inderal.

Past Medical History: No significant past medical problems

Social History: Denies using caffeinated beverages or alcohol. Smokes 2 packs of cigarettes per day.

Family History: Father died of sudden cardiac death at age of 50.

Review of Systems: Generally healthy. The patient is a good historian.

Examination:Exam Abdomen/Flank: The abdomen is soft without tenderness or palpable masses. No guarding, rigidity or rebound tenderness. The liver and spleen are not palpable. Bowel sounds are active and normal.

Exam Extremities: Lower extremities are normal in color, touch and temperature. No ischemic changes are noted. Range of motion is normal. There is no cyanosis, clubbing or edema.

General: Healthy appearing, well developed. The patient is in no acute distress.

Exam Skin Negative to inspection or palpation. There are no obvious lesions or new rashes noted. Non-diaphoretic.

Exam Ears Canals are clear. Throat is not injected. Tonsils are not swollen or injected.

Exam Neck: There is no thyromegaly, carotid bruits, lymphadenopathy, or JVD. Neck is supple.

Exam Respiratory: Normal breath sounds are heard bilaterally. There is no wheezing. There is no use of accessory muscles.

Exam Cardiovascular: Regular heart rate and rhythm, Normal S1 and S2 without murmur, gallops or rubs.

Impression/Diagnosis: Precordial chest pain and palpitations in a hypertensive patient.

Tests Ordered: Cardiac tests: Echocardiogram.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 7I had the pleasure of seeing the patient back again. He has not obtained diabetic shoes at this point. He has pain in both feet and his low back. He is on Motrin.

His exam demonstrates a healing ulcer on the plantar aspect of the right IP joint of the great toe. There is overlying callus fissures, no evidence of infection and decrease in size. The ulcer is open through the epidermis into the dermis.

Impression: 1. Diabetic wound right great toe.

Plan: The wound is debrided and the patient is given instructions to the wound care. He desperately needs diabetic shoes. We will talk about this again. I will see if I can see him in two weeks to begin a more active role.

ICD-10-CM code(s): ________________________________________

Case 8History of Present Illness: The patient is here for recheck of his diastolic congestive heart failure. He is status post mechanical aortic valve replacement on 10/15/2009 for which he has been on chronic anticoagulation.

Review of Systems:General: Unremarkable. Cardiopulmonary: No chest pain, shortness of breath, palpitations, or dizziness. Gastrointestinal: Unremarkable. Musculoskeletal: Unremarkable. Neurologic: Unremarkable.

Family History: There are no family members with coronary artery disease. His mother has congestive heart failure.

Social History: The patient is married. He lives with his wife. He is employed as a barber. He does not use alcohol, tobacco, or illicit drugs.

Allergies: None.

Physical Examination:General: A well-appearing, obese black male.

Vital Signs: BP 140/80, HR 88, respirations 16, and afebrile.

HEENT: Grossly normal.

Neck: Normal. Thyroid, normal. Carotid, normal upstroke, no bruits.

Chest: Midline sternotomy scar.

Lungs: Clear.


Case Studies

Heart: PMI fifth intercostal space mid clavicular line. Normal S1 and prosthetic S2. No murmur, rub, gallop, or click.

Abdomen: Soft and nontender. No palpable mass or hepatosplenomegaly.

Extremities: Normal. No edema. Pulses bilaterally intact, carotid, radial, femoral, and dorsalis pedis. Neurologic: Mental status, no gross cranial nerve, motor, or sensory deficits.

Impression: 1. Congestive heart failure, diastolic, chronic, stable, NYSHA class I to II.

2. Status post aortic valve replacement 10/15/2009 on chronic anticoagulation.

ICD-10-CM code(s): ________________________________________

Case 9Subjective: The daughter brings this patient in because the right ear had started draining. The patient was strongly advised to leave the hearing aid out of that ear.

Objective: Under the microscope, there is gross pus in the ear canal. It was cleaned and 5 drops of ofloxacin placed in the ear.

Assessment: Acute otitis media on the right.

Plan: Ofloxacin 5 drops b.i.d. x10 days. I also put in a prescription for Claritin 10 mg per day. The patient was advised to return in 2 weeks if the ear continued to drain. Otherwise, he will keep the appointment next month.

ICD-10-CM code(s): ________________________________________

Case 10Jack presents with 6 weeks of nasal congestion, yellow-green sinus drainage, fatigue, and intermittent facial and head pain. His symptoms started as a post-nasal drip, and then progressed to nasal congestion with the aformentioned sinus drainage. He initially was treated with 10 days of oral clarithromycin and an extended-release guafenesin-pseudoephedrine product, with no relief. His symptoms did abate temporarily, but then returned with similar intensity.

On examination, there is again injection and erythema of the turbinates, this time with visible purulent nasal discharge. There is severe facial tenderness to percussion. The remainder of the ENT examination is within normal limits.

Acute maxillary sinusitis. The patient is switched to oral levofloxacin for 10 days and continues on the guafenesin + pseudoephedrine. Will see back in 14 days.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 11Subjective: This 23-year-old white female presents with complaint of allergies. She used to have allergies when she lived in Seattle but she thinks they are worse here. In the past, she has tried Claritin, and Zyrtec. Both worked for short time but then seemed to lose effectiveness. She has used Allegra also. She used that last summer and she began using it again two weeks ago. It does not appear to be working very well. She has used over-the-counter sprays but no prescription nasal sprays. She does have asthma but does not require daily medication for this and does not think it is flaring up. She does not wake at night with symptoms and has only had to use her rescue inhaler once in the past month.

Medications: Her only medication is Ortho Tri-Cyclen and the Allegra.

Allergies: She has no known medicine allergies.

Objective:Vitals: Weight was 130 pounds and blood pressure 124/78.

HEENT: Her throat was mildly erythematous without exudate. Nasal mucosa was erythematous and swollen. Only clear drainage was seen. TMs were clear.

Neck: Supple without adenopathy.

Lungs: Clear.

Assessment: Allergic rhinitis. Mild intermittent asthma. Patient had not done an asthma action plan in some time, so today we did a new one. She did a new peak flow and we discussed her personalized green, yellow, and red zones for her plan.

Plan:

1. She will try Zyrtec instead of Allegra again. Another option will be to use loratadine. She does not think she has prescription coverage so that might be cheaper.

2. Samples of Nasonex two sprays in each nostril given for three weeks. A prescription was written as well.

3. Gave patient refills of her Advair and Proventil inhaler.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 12Subjective: This is a 29-year-old female, established patient, last seen in our office on 07/13. She comes in today for a rash under both breasts. She was on vacation in Miami, where it was very humid, when the rash began. It has progressed to where it is red, raw, and burns when touched. She did not burn while on the trip.

Physical Examination: Patient is a large-breasted woman. Patient states it is hard to keep the breasts from rubbing on the skin folds underneath.The area under both breasts is reddened and raw-looking. It is painful to the touch upon exam.

Impression/Plan: Erythema intertrigo. Patient to leave bra off when possible to allow air to keep area dry and moisture free. Told patient to clean the area twice a day with a mild soap and allow to air dry. Also instructed that she may use an antibiotic cream if desired. Will return in one week if not better.

ICD-10-CM code(s): ________________________________________

Case 13Bernie presents today for hemorrhoid banding. On a previous visit, he complained of blood in his stool and frequent hard bowel movements. His exam in the office revealed internal hemorrhoids. I sent him for colonoscopy for definitive diagnosis and to rule out any other issue. Colonoscopy showed colon polyp and confirmed grade II internal hemorrhoids. We discussed various treatment options and the patient decided to undergo hemorrhoid band ligation therapy. He presents for his first treatment today.

We utilized the CRS O’Regan system to band ligate several internal hemorrhoids. The patient did not complain of any pain during or after the procedure. We discussed proper bowel habits at length and I detailed ways of preventing his hemorrhoids from returning.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 14S—An 83-year-old patient presents with difficulty walking.

O— On examination, the lateral aspect of her left great toenail is deeply ingrown. Her toenails are thick and opaque. Vibratory sensation appears to be intact. Dorsal pedal pulses are 1/4. There is no hair growth seen on her toes, feet or lower legs. Her feet are warm to the touch. All of her toenails are hypertrophic, opaque, elongated and discolored.

A—1. Onychocryptosis. 2. Onychomycosis.

P— Aseptic technique was used and the lateral aspect of the left great toenail was excised. Blood loss was minimal. Hemostasis was achieved. Her left great toe was dressed with Neosporin ointment and absorbent dressing. Her remaining toenails required manual as well as electric debridement. Follow-up is every three months or whenever she needs to come in.

ICD-10-CM code(s): ________________________________________

Case 15Reason for Visit: Elevated PSA with nocturia

History: A 68-year-old male with a history of frequency and some outlet obstructive issues along with irritative issues. The patient has had history of an elevated PSA and PSA in 2012 was 5.5. In 2011, he had undergone a biopsy by Dr. X, which was negative for adenocarcinoma of the prostate. The patient has had PSAs as high as noted above. His PSAs have been as low as 1.6, but those were on Proscar. He otherwise appears to be doing reasonably well, off the Proscar, otherwise does have some irritative symptoms. This has been ongoing for greater than five years. No other associated symptoms or modifying factors. Severity is moderate. PSA relatively stable over time. There is a family history of prostate cancer in his father and grandfather.

Impression: 1. Elevated PSA, stabilized over time, although he does have some irritative symptoms. 2. Nocturia. After our discussion, it does appear that if he is not drinking close to going to bed, he notes that his nocturia is decreased. At this juncture what I would like to do is to start with behavior modification. There were no other associated symptoms or modifying factors.

Plan: The patient will discontinue all caffeinated and carbonated beverages and any fluids three hours prior to going to bed. He already knows that this does decrease his nocturia. He will do this without medications to see how well he does and hopefully he may need no other additional medications other than may be changing his alpha-blocker to something of more efficacious.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 16Chief Complaint: Follow-up on hypertension and hypercholesterolemia.

Subjective: This is a 78-year-old male here in follow-up. He does most of the things that he wants to do. He travels at every chance he has, and he just got back from a cruise. He denies any type of chest pain, heaviness, tightness, pressure, shortness of breath with stairs only, cough or palpitations. He sees Dr. Ferguson for Crohn’s. He sees Dr. Roszhart for his prostate check. He is a nonsmoker and denies swelling in his ankles.

Medications: Refer to chart.

Allergies: Refer to chart.

Physical Examination: Vitals: Wt; 172 lbs, up 2 lbs, B/P; 150/60, T; 96.4, P; 72 and regular. General: A 78-year-old male who does not appear to be in any acute distress. Glasses. Good dentition. CV: Distant S1, S2 without murmur or gallop. No carotid bruits. P: 2+ all around. Lungs: Diminished with increased AP diameter. Abdomen: Soft, bowel sounds active x 4 quadrants. No tenderness, no distention, no masses or organomegaly noted. Extremities: Well-healed surgical scar on the right knee. No edema. Hand grasps are strong and equal. Neuro: Intact. A&O. Moves all four with no focal motor or sensory deficits.

Impression:1. Hypertension. 2. Hypercholesterolemia.

Plan: We will check a BMP, lipid, liver profile, CPK, and CBC. Refill his medications x 3 months. Increase his Altace to 5 mg day for better blood pressure control. Diet, exercise, and weight loss, and we will see him back in three months and p.r.n.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 17S: Cheryl is in today not feeling well for the last three days. She is a bit sick with body aches. She is

coughing. She has a sore throat, especially when she coughs. Her cough is productive of green colored sputum. She has had some chills. No vomiting. No diarrhea. She is sleeping okay. She does not feel like she needs anything for the cough. She did call in yesterday, and got a refill of her Keflex. She took two Keflex this morning and she is feeling a little bit better now. She is tearful, just tired of feeling ran down.

O: Vital signs as per chart. Respirations 15. Exam: Nontoxic. No acute distress. Alert and oriented. HEENT: TMs are clear bilaterally without erythema or bulging. Clear external canals. Clear tympanic. Conjunctivae are clear. Clear nasal mucosa. Clear oropharynx with moist mucous membranes. NECK is soft and supple without lymphadenopathy. LUNGS are coarse with no severe rhonchi or wheezes. HEART is regular rate and rhythm without murmur. ABDOMEN is soft and nontender.

Chest X-ray reveals no obvious consolidation or infiltrates. We will send the X-ray for over-read. Influenza test is negative. Rapid strep screen is negative.

A: Acute Bronchitis.

P: 1. Motrin as needed for fever and discomfort.2. Push fluids. 3. Continue on the Keflex.

ICD-10-CM code(s): ________________________________________

Case 18Chief Complaint: Right knee pain.

History of the Present Illness: The patient presents today for follow up of osteoarthritis Grade IV of the bilateral knees and flexion contracture, doing great. Physical therapy is helping. The subjective pain is on the bilateral knees right worse than left. Quality: There is no swelling, no redness, or warmth. The pain is described as aching occasionally. There is no burning. Duration: Months. Associated symptoms: Includes stiffness and weakness. There is no sleep loss and no instability. Hip Pain: None. Back pain: None. Radicular type pain: None. Modifying factors: Includes weight bearing pain and pain with ambulation. There is no sitting, and no night pain. There is no pain with weather change.

Viscosupplementation in Past: No Synvisc.

Vas Pain Score: 10 bilaterally.

Review of Systems: No change.Constitutional: Good appetite and energy. No fever. No general complaints. HEENT: No headaches, no difficulty swallowing, no change in vision, no change in hearing. CV—RESP: No shortness of breath at rest or with exertion. No paroxysmal nocturnal dyspnea, orthopnea, and without significant cough, hemoptysis, or sputum. No chest pain on exertion. GI: Clear without nausea—vomiting—and absent of diarrhea. Absent of abdominal pain. No complaints of dyspepsia. No dysphagia. No hematochezia, and no melena.


Case Studies

Skin: No lesions seen. Neurological: No signs or symptoms are reported. No TIA or CVA symptoms are reported. No radicular pain is reported.

Objective: No change.Head: Normocephalic, atraumatic, and no headaches. Neck: Full range of motion. Lymph nodes: No abnormalities noted. Respiratory: Stable respiratory rate. Lung fields are clear. Cardiovascular: Regular rate and rhythm without murmurs, gallops, or rubs Abdomen: Non-tender, no palpable masses. Spine w/ pelvis: Full range of motion. No spine tenderness. Skin: No rash or lesions noted. Neurovascular: Grossly intact. Psycho: Awake, alert, and oriented times 4. No depression.

Knee Examination: The patient comes to the clinic today and is full weight bearing. Exam of the right knee shows neurovascular status is normal. The skin reveals a scar. Crepitance is 2, and active range of motion is 10 to 110 degrees and passive range of motion is 7 to 120 degrees. There is a flexion contracture at 10 degrees, right knee. Effusion is 0 and ligaments are normal. The meniscal signs are absent. Exam of the left knee shows neurovascular status is normal. The skin reveals a scar. Crepitance is 2, and range of motion is 5 to 120 degrees. Effusion is 0 and ligaments are normal. The meniscal signs are absent.

Diagnoses: Osteoarthritis.

Recommendations—Plan of Treatment: 1. Excellent results with physical therapy.

2. Continue physical therapy.

3. Refill pain medication on a p. r. n. basis.

ICD-10-CM code(s): ________________________________________

Case 19Jane is 5-years-old and is seen in our office today 2 weeks after being placed into a cast for a nondisplaced fracture of the left distal radius. She was playing on the monkey bars and FOOSH. Her mother brought her in because she had some bruising, a little swelling, and said it was sore. After X-ray she was found to have a nondisplaced fracture. A cast was placed. Mother reports that she stopped giving her the Tylenol with codeine elixir before the end of the first week. The cast is windowed and new X-rays were taken which show the fracture to be healing well. Patient to return back in 2 weeks, sooner if there are any problems.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 20History of Present Illness: This 59-year-old white male is seen for comprehensive annual health maintenance examination. He is in excellent overall health. Medical problems include dyslipidemia well controlled with niacin, and also history of concha bullosa of the left nostril, followed by ENT associated with slight septal deviation. There are no other medical problems. He has no symptoms at this time and remains in excellent health.

Past Medical History: Otherwise noncontributory. There is no operation, serious illness or injury other than as noted above.

Allergies: There are no known allergies.

Family History: Father died at age 67 with COPD and was a heavy smoker. His mother is 88, living and well. Two brothers, living and well. One sister died at age 20 months of pneumonia.

Social History: The patient is married. Wife is living and well. He jogs or does Cross Country track 5 times a week, and weight training twice weekly. No smoking or significant alcohol intake. He is a physician.

Review of Systems: Otherwise noncontributory. He has no gastrointestinal, cardiopulmonary, genitourinary or musculoskeletal symptomatology. No symptoms other than as described above.

Physical Examination: GENERAL: He appears alert, oriented, and in no acute distress with excellent cognitive function. VITAL SIGNS: His height is 6 feet 2 inches, weight is 181.2, blood pressure is 126/80 in the right arm, 122/78 in the left arm, pulse rate is 68 and regular, and respirations are 16. SKIN: Warm and dry. There is no pallor, cyanosis or icterus. HEENT: Tympanic membranes benign. The pharynx is benign. Nasal mucosa is intact. Pupils are round, regular, and equal, reacting equally to light and accommodation. EOM intact. Fundi reveal flat discs with clear margins. Normal vasculature. No hemorrhages, exudates or microaneurysms. No thyroid enlargement. There is no lymphadenopathy. LUNGS: Clear to percussion and auscultation. NSR. No premature beat, murmur, S3 or S4. Heart sounds are of good quality and intensity. The carotids, femorals, dorsalis pedis, and posterior tibial pulsations are brisk, equal, and active bilaterally. ABDOMEN: Benign without guarding, rigidity, tenderness, mass or organomegaly. NEUROLOGIC: Grossly intact. EXTREMITIES: Normal. GU: Genitalia normal. There are no inguinal hernias. The prostate is small, if any normal to mildly enlarged with discrete margins, symmetrical without significant palpable abnormality. There is no rectal mass. The stool is Hemoccult negative.Impression: 1. Comprehensive annual health maintenance examination.

2. Dyslipidemia.

Plan: At this time, continue niacin 1000 mg in the morning, 500 mg at noon, and 1000 mg in the evening; aspirin 81 mg daily; multivitamins; vitamin E 400 units daily; and vitamin C 500 mg daily. Consider adding lycopene, selenium, and flaxseed to his regimen. All appropriate labs will be obtained today. Follow-up fasting lipid profile and ALT in 6 months.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 21S: The patient presents for back pain that has been present for just a few days and is slightly worse

with movement. He has had pains in his elbows for approximately four months. It is relatively constant, not extreme. It does tend to hurt when he supinates his forearm fully. He has also had some mild pain in the back. At one time, he was thought to possibly have cervical disc disease; however, a CT scan of the cervical spine was unremarkable. He has no other significant history. Social: He is a nonsmoker. Family history: His father does have some mild arthritis and also has hypertension and heart disease.

O: HEENT: Tympanic membranes are clear bilaterally. Nose and throat are clear. Neck is supple without lymphadenopathy or bruits. Cardiovascular: Regular rate and rhythm without murmur. Abdomen: Soft, flat, nontender, and nondistended. Bowel sounds are active. He has some minimal tenderness in the right lower quadrant. Back: There is trigger-point tenderness. Lower extremities are normal to exam. He has negative straight leg raising in the supine position. Laboratory studies were within normal limits, with the exception of his cholesterol which was 236 and his triglycerides which were 320. He is not watching his diet at all.

A: Strain of the lower back. Bilateral elbow joint pain.

P: He is to take the strain off of his elbows and lower back. I also gave him an instruction sheet on a low-cholesterol diet. He will try to follow this for six months, and we will recheck his cholesterol then. He asked if I would recommend taking niacin. I told him that it might have some beneficial effect and was probably relatively safe for him to take.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 22The patient is a 59-year-old Caucasian female, with right knee pain and off for the last 8 years. She states that the pain increases with activities and decreased with activities. It decreases with rest. She states that her pain level is 5/10. She states that she has good days and bad days. The patient states that she has night pain. The patient has stiffness. The patient denies catching, popping or locking. The patient states that she has difficulty getting out of a chair, getting out of a car, sitting, standing and walking, both on flat and incline surfaces. She has been treated with Relafen, Celebrex and Motrin over the years with minimal effect. Examination of the right knee demonstrates no effusion. The knee is in 10 degrees of varus. There is medial and lateral joint line tenderness. There is reduced painful forced flexion. Extension is full. There is a negative Lachman test. The patella is nontender. Examination of left knee is within normal limits.

X-ray: X-ray of the right knee demonstrates decreased medial joint space, subchondral sclerosis and spiking of the tibial spines. These findings are compatible with degenerative joint disease.

Impression: 1. Primary osteoarthritis right knee.

Treatment: The knee was sterilely prepped and injected with steroid and Lidocaine preparation. She is given a prescription for physical therapy for the right knee. She will not wear any form of immobilization, since she has had a saphenous vein stripping in the past. She will be seen again in four weeks.

The patient was given a prescription for Relafen 750 mg, b.i.d.

ICD-10-CM code(s): ________________________________________

Case 23Gary comes in today with his sister, who assists with helping him adhere to his treatment plan for his bipolar affective disorder.

Chief Compliant: “I’m here because I’m different.” The patient exhibits poor insight into illness and need for treatment.

History of Present Illness: The patient has a history of bipolar affective disorder and poor outpatient compliance. According to his sister, he has not been compliant with medications or outpatient follow-up, and over the past several weeks, the patient had become increasingly labile. His sister has found that he has not been sleeping. The patient had expressed grandiose delusions that he is Martin Luther King, and was found recently at a local church agitated throwing a pew and a lectern and required police intervention. At today’s visit, the patient remains euphoric with poor insight.

Past Psychiatric History: History of bipolar affective disorder. The patient has been treated with Depakote and Seroquel, but has had no recent treatment or follow-up. Dates of previous hospitalizations are not known.

Current Medications: None.

Family Social History: Unemployed. The patient resides with his sister and her family. The patient denies recent substance abuse.


Case Studies

Mental Status Examination: | Attitude: Suspicious, but cooperative. Appearance: Shows appropriate hygiene and grooming. Psychomotor Behavior: Within normal limits. No agitation or retardation. No EPS or TDS noted. Affect: Labile. Mood: Euphoric. Speech: Pressured. Thoughts: Disorganized. Thought Content: Remarkable for grandiose delusions as noted. The patient denies auditory hallucinations. Psychosis: Grandiose delusions as noted above. Suicidal/Homicidal Ideation: The patient denies. Cognitive Assessment: Grossly intact. The patient is oriented x 3. Judgment: Poor shown by noncompliance to the outpatient treatment. Assets: Include stable physical status. Limitations: Include recurrent psychosis.Impression: Bipolar disorder with current severe manic episode. Patient to be admitted for increasing mood lability, psychotic features, and noncompliance to the outpatient treatment. Discussed his case with the on-call Psychiatrist for the hospital. The patient will be placed on Depakote for mood lability and Seroquel for psychosis and his response will be monitored closely. The patient will be evaluated for more structural outpatient follow-up following stabilization. Estimated length of stay: 12 days.

ICD-10-CM code(s): ________________________________________

Case 24Janet comes in today stating “I think I am going crazy.” She says for the past three months she has been experiencing abrupt episodes of palpitations, sweating, trembling, shortness of breath, chest pain, and dizziness. The first time this happened she was walking down the stairs not thinking of “anything in particular”. The episode lasted about 15 minutes. Although the patient said it felt much longer. She now has episodes once or twice a day that happen at different times under different situations. Now she worries when another attack will occur. She has been to the ED twice when she thought she was having an attack, but physical and lab findings have been normal. Patient does not smoke or drink alcohol. Physical examination is completely normal.

Panic disorder. We discussed cognitive behavior therapy and SSRIs were prescribed. She will return in one week, sooner if she feels necessary.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 25Jack presents with complaints of abdominal pain. He is a 36-year-old high school teacher. The pain is located in the epigastrium and has become relatively constant. Jack states that he was well until six months ago, when he began to suffer periodic attacks of nausea, heartburn, and diffuse epigastric pain. During these periods the pain worsens when the stomach is empty and relieved by food and antacids. Jack states that he was “dealing with the pain”, but it has now starting to interfere with his work and leisure activities. He had to call in sick this week. Upon exam, his temperature is normal, pulse rate only slightly elevated, and blood pressure normal. 10 lb weight loss noted. There is a board-like rigidity on the abdomen, most marked in the epigastric area and left hypochondriac region and somewhat less pronounced in the umbilical region. IMPRESSION: Epigastric pain. Patient was informed of probable diagnosis of gastric ulcer. Patient will be sent for an upper GI. Informed patient, for now, to refrain from drinking caffeinated beverages, alcohol, and NSAIDs.

ICD-10-CM code(s): ________________________________________

Case 26Tricia is brought in by her mother for assessment. She is 7-years-old. She is brought in by suggestion of her second grade teacher. She has been back to school for three weeks following summer break. According to the teacher, Tricia has found it difficult to complete her classroom tasks. She is not really disruptive, but cannot finish her assignments in the allotted time, although her classmates do so without difficulty. She is also noted to make careless mistakes in her work. She is still passing her classes, but her grades have dropped on her assignments and she daydreams a lot during class. The teacher states it takes several repetitions of the instructions for her to complete tasks. She enjoys gym class and does well in that capacity. She states that when people think she is not paying attention she is thinking of other things. Her teacher reports that her attention wanders constantly and she has to call Tricia’s name or wave to get her attention. There have been no episodes where she stares blankly. She had some of these same issues last year, but they now seem to be exacerbated.

Her mother states that she has noticed some of the same behaviors at home, but states she has found ways to “work around them”. If she monitors her work directly, she can complete her homework, but she has to continually check her to keep her on track. She also has to check her work for careless mistakes. When they are pointed out, she knows the right answer. She also has great trouble getting ready for school in the morning. It requires minute-by-minute monitoring to keep her moving. Her bedroom is in constant shambles, and she loses things all the time. Her mother states she is a happy child that enjoys playing with her friends, but does not enjoy school, except for gym.

Attention deficit hyperactivity disorder, inattentive type. Appointment to be made with the Behavioral Psychologist to help the family with improving Tricia’s organizational skills, study techniques, and social functioning.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 27Father brings in Dave today with complaints of decrease hearing for about a week. He states that he and his wife noticed that Dave was not responding when they called him. The father states that Dave was in the kitchen with his back to him. He called to him, but he did not acknowledge him. He thought he was ignoring him, so he walked up to him. When he walked around in front of Dave, he kind of jumped, like he did not know he was there. He is exposed to second hand cigarette smoke in the home. Father has noted no fever or discharge from the ears. Dave just got over a cold last week.

Exam: NAD. Patient is well-developed, well-nourished 2-year-old child within the 90% on his age height and weight scales. Using binocular microscope, exam of the ears reveals large cerumen impaction and the TMs cannot be visualized. Bilateral impaction removed by curette. The TMs were then noted to be red and inflamed. Nasal and oral mucosa moist. Neck is supple. No lymphadenopathy.

Imp: Cerumen impaction bilaterally. Acute bilateral otitis media with effusion (ABOME) with second hand smoke exposure. Will send Dave for hearing test. Patient to be brought back after testing to determine any next steps necessary.

ICD-10-CM code(s): ________________________________________

Case 28Julie comes in today for a check-up on her interstitial cystitis. She had been suffering symptoms on and off for years, but urine studies were always negative. Her diagnosis was confirmed by cystoscopy. Her urinary frequency, urgency, and pelvic pain are all still present at times, but have lessened with the new behavioral adjustments that we have introduced. Julie states that the biofeedback has helped with her urgency and frequency. She stopped drinking coffee and eating spicy foods. She has cut down on her tomato consumption. She states all of these things helped her symptoms.

Upon exam, her vital signs are stable. U/A again is negative. Lungs: clear. CV: RRR. ENMT: PERRLA, MMM. Abdomen: Suprapubic tenderness.

Interstitial cystitis with urinary frequency, urgency, and pelvic pain under better control. Continue with behavior modifications, voiding diary. Patient to come back in 3 months, sooner if conditions flair.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 29Phil is coming in today for a check on his hypertension, CKD stage 3, and morbid obesity. He has a BMI of 42. He has never smoked and is negative for diabetes or proteinuria. He states he is feeling well and is working on his diet and lifestyle modifications to lose weight. His blood pressure is 145/95 (last measurement 165/102). Current weight 275 lbs (15 lb loss). His most recent labs are as follows:

Serum potassium = 4.4 mmol/litre

Serum creatinine = 260 micromol/litre

eGFR = 33 mL/minute/1.73 m2

Fasting total cholesterol = 3.4 mmol/litre

Liver function and other U + Es are normal

His medications include: lisinopril 20 mg daily, bendroflumethiazide 2.5 mg daily, simvastatin 40 mg daily.

Will continue current meds. Discussed continued weight loss measures with the patient. He states he is starting with a personal trainer this week.

ICD-10-CM code(s): ________________________________________

Case 30Mary presents today for worsening dyspnea and cough. She is a 60-year-old woman with a 3-year history of diabetes. She has had chronic obstructive pulmonary disease (COPD) since age 55. She complains of dyspnea with walking one-third of a block and a persistent cough. Her type 2 diabetes has been managed with diet and exercise. Her last glycosylated hemoglobin measured 1 month ago was 6.8% (normal 4–6%). She continues to smoke 1 pack of cigarettes per day. She has stated that she has smoked for over 30 years and has no desire to quit at this time.

Physical exam reveals an anxious woman with blood pressure 130/70 mm Hg, pulse 120, respiratory rate 24, and weight 180 lb. Lungs are clear to percussion, but wheezing is present bilaterally. No accessory muscles are being used. No cyanosis is present.

Lab evaluation: ABG: 7.46; pO2: 60; pCO2: 40; O2 Sat: 88%. Chest X-ray: flat diaphragms hyperinflated, no infiltrates. Spirometry: forced vitality capacity (FVC): 3.2; forced expiratory time in 1 second (FeV1): 1.4.

Type 2 diabetes mellitus, well controlled. COPD with exacerbation. Will start her on albuterol and begin on a course of prednisone at 40 mg/day for 3 days, tapering over 2 weeks. Will keep close eye on glucose due to steroids.

Tobacco dependence. Patient does not desire counseling or assistance with quitting at this time.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 31CC: Fall and laceration.

HPI: Jake comes in today as a walk-n. He was running down the sidewalk to catch a taxi when he stumbled, fell and struck his face on the sidewalk. He denies loss of consciousness but says he was dazed for a minute after it happened. He complains of pain over the chin and right forehead where he has lacerations and abrasions. He denies neck pain, back pain, extremity pain or pain in the abdomen.

Meds: None. ROS: As above. Otherwise negative.

Physical Exam: He is in no apparent distress. Vital Signs: BP 165/95 HR 80 RR 12 Temp 98.4 SpO2 95% HEENT: No palpable step offs, there is blood over the right eyebrow where there is a small 1cm laceration and surrounding abrasion. Also, 2 cm laceration over the base of the chin without communication to the oro-pharynx. No other trauma noted. No septal hematoma. No other facial bony tenderness. Neck: Nontender Chest: Breathing comfortably; equal breath sounds. Heart: Regular rhythm. Abd: Benign. Ext: No tenderness or deformity; pulses are equal throughout; good cap refill Neuro: Awake and alert; moves all extremities; cranial nerves normal.

Laceration right eyebrow. Laceration chin. The lacerations were explored and no foreign body found. They were irrigated and closed with simple interrupted sutures.

ICD-10-CM code(s): ________________________________________

Case 32History of Present Illness: Martha presents for follow-up. I have been following her for her pancytopenia. After several bone marrow biopsies, she was diagnosed with aplastic anemia. She started cyclosporine and prednisone on 03/30/XX. Overall, she tells me that now she feels quite well. Repeat CBC shows white blood cell count of 3.4 with a hemoglobin of 10.7 and platelet count of 49,000.

Current Medications: Folic acid, Aciphex, MiraLax, trazodone, prednisone for 5 days every 4 weeks, Bactrim double strength 1 tablet b.i.d. on Mondays, Wednesdays and Fridays.

Review of Systems: As per the HPI, otherwise negative.

Social History: She has no tobacco use. She has rare alcohol use. She has three children and is a widow. She is retired.

Physical Exam: VIT: Height 167 cm, weight 66 kg, blood pressure 122/70, pulse 84, and temperature is 98.9. GEN: She is nontoxic, noncachectic appearing. EYES: Anicteric. ENT: No oropharyngeal lesions.


Case Studies

LYMPH: No cervical, supraclavicular, or axillary lymphadenopathy. HEART: Regular S1, S2; no murmurs, rubs, or gallops. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Non tender, non distended; NABS; no HSM. EXT: Reveal no edema.Assessment/Plan: Pancytopenia with aplastic anemia. We will continue with monthly CBCs for now and I will see her again in one month.

ICD-10-CM code(s): ________________________________________

Case 33Subjective: The patient seen and examined feels better today. Still having diarrhea, decreased appetite. Good urine output 600 mL since 7 o’clock in the morning. Afebrile.

Physical Examination: GENERAL: No acute distress, awake, alert, and oriented x3. VITAL SIGNS: Blood pressure 102/64, heart rate of 89, respiratory rate of 12, temperature 96.8, and O2 saturation 94% on room air.HEENT: PERRLA, EOMI. NECK: Supple. CV/RESPIRATORY: RRR. CTAB. ABDOMEN: Bowel sounds are positive, soft, and nontender. EXTREMITIES: No edema. Pulses present bilaterally.Laboratory Data: CBC, WBC count today down 10.9 from 17.3 yesterday 26.9 on admission, hemoglobin 10.2, hematocrit 31.3, and platelet count 370,000. Liver function test is unremarkable.

Stool positive for Clostridium difficile. Blood culture was 131. O2 saturation result is pending.

Assessment and Plan: C-diff colitis, Continue Flagyl.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 34Subjective: The patient states that he feels sick and weak. Mike reports he has decreased urine output, increased thirst, and some dizziness.

Physical Examination: VITAL SIGNS: Highest temperature recorded over the past 24 hours was 102.1, and current temperature is 100.2. GENERAL: The patient looks tired. HEENT: Oral mucosa is dry. CHEST: Clear to auscultation. He states that he has a mild cough, not productive. CARDIOVASCULAR: First and second heart sounds were heard. No murmur was appreciated. ABDOMEN: Soft and non tender. Bowel sounds are positive. Murphy’s sign is negative. EXTREMITIES: There is no swelling. NEURO: The patient is alert and oriented x 3. Examination is nonfocal.Laboratory Data: White count is normal at 6.8, hemoglobin is 15.8, and platelets 257,000. Glucose is in the low 100s. Comprehensive metabolic panel is unremarkable. UA is negative for infection.

Assessment And Plan: 1. Fever of undetermined origin, probably viral since white count is normal. Would continue

current antibiotics empirically.

2. Dehydration. Hydrate the patient.

ICD-10-CM code(s): ________________________________________

Case 35S: Victoria is brought in by her mother today with a fever of 102, headache, and sore throat. She

had a sleepover last week with a friend who was found to have strep throat. She presently denies any shortness of breath, difficulty breathing, chest pain, lightheadedness, dizziness, or loss of consciousness. She says she just feels “icky”.

O: HEENT: TMs are dull and immobile. Sinuses are nontender. Nares are normal. Throat is very red. Neck is supple with two lymph nodes on the right. Cardiac: Regular rate and rhythm, no murmurs. Lungs: CTA, no CVAT. Rapid strep is positive.

A: Strep throat.

P: Amoxicillin prescription given. Motrin as needed for fever and discomfort. Push fluids. Can have popsicles to help with sore throat.

ICD-10-CM code(s): ________________________________________


Case Studies

Case 36Reason for Visit: Overactive bladder with microscopic hematuria.

History of Present Illness: The patient is a 56-year-old noted to have microscopic hematuria and overactive bladder. Her cystoscopy performed was unremarkable. She continues to have some episodes of frequency and urgency mostly with episodes during the day and rare at night. No gross hematuria, dysuria, pyuria, no other outlet obstructive and/or irritative voiding symptoms. The patient had been previously on Ditropan and did not do nearly as well. At this point, what we will try is a different medication. Renal ultrasound is otherwise unremarkable, notes no evidence of any other disease.

Impression: Overactive bladder and microscopic hematuria. She has no other significant findings other than her overactive bladder, which had continued. At this juncture what I would like to do is try a different anticholinergic medication. She has never had any side effects from her medication.

Plan: The patient will discontinue Ditropan. We will start Sanctura XR and we will follow up as scheduled. For the microscopic hematuria, we will perform follow-up urinalysis and cytology at 6 months.

ICD-10-CM code(s): ________________________________________

Case 37Jackie is here for a check-up on her migraines. She has had migraines for the past 9 years. Her “attacks” used to last between 12-20 hours with throbbing pain, photophobia, vomiting, and blurred vision. She does not have preceding aura. She states the propranolol continues to help keep her migraine attacks in check. When she does have a migraine, Treximet is successful in relieving her symptoms. She also has decreased postdrome length and severity.

VITAL SIGNS: Blood pressure of 115/66, heart rate of 69, respiratory rate of 13, temperature normal, and pulse oximetry 98% on room air at the time of initial evaluation.

HEENT: Head, normocephalic, atraumatic. Neck supple. Throat clear. No discharge from the ears or nose. No discoloration of conjunctivae and sclerae. No bruits auscultated over temple, orbits, or the neck.

LUNGS: Clear to auscultation.

CARDIOVASCULAR: Normal heart sounds.

ABDOMEN: Benign.

EXTREMITIES: No edema, clubbing or cyanosis.

SKIN: No rash. No neurocutaneous disorder.

NEURO: The patient is awake, alert and oriented to place and person. Speech is fluent. No language deficits. Mood normal. Affect is clear. Memory and insight is normal. No abnormality with thought processing and thought content. Cranial nerve examination intact II through XII. Motor


Case Studies

examination: Normal bulk, tone and power. Deep tendon reflexes symmetrical. Downgoing toes. No sign of any myelopathy. Cortical sensation intact. Peripheral sensation grossly intact.

Patient with chronic migraine, without aura, not intractable. Doing well on medications. Continue present management. Patient to follow up as necessary.

ICD-10-CM code(s): ________________________________________

Case 38Jill presents today with complaint of skin rash on her forehead that has developed over the past several months. She states that she sometimes has a burning sensation of the rash and sensitivity to touch. Patient loves being out in the sun and rarely uses sunscreen on her face. She considered the fact that she wore make-up as protection. She states that she was recently on a cruise and in the sun every day. She also states that she wishes to have her skin tags removed along her bra line as they are becoming more bothersome. She says that they get irritated often from her bra rubbing against them.

Exam reveals significant photodamage and presence of several actinic keratosis, that are too numerous to count. Exam of trunk also shows twenty counted acrochordon along the bra line. These were removed by scissor with no problem. Covered so that bra would not rub.

Acrochordon and AK of forehead due to sun damage. Due to the large skin area and number of AKs, field-directed therapy chosen. Patient to be treated with f-FU 0.5% for 4 weeks. Explained she is to apply once daily to entire forehead while wearing gloves. Patient counseled on inflammatory response expected with severe skin irritation.

ICD-10-CM code(s): ________________________________________

Case 39Bob comes in today complaining of pain in his right hand. He was well until a little over a week ago, when he sustained a deep scratch on his right hand while playing with his cat. He washed the wound and bandaged it tightly to stop the bleeding. Over the following days, however, his palm began to swell, turned red, and became increasingly painful. His blood pressure is 120/70 mm Hg, heart rate is 90 beats per minute, respiratory rate is 12 per minute, and temperature is 101.3. He recalls having had a tetanus booster shot 7 years ago. His cat has received all appropriate vaccinations, and is apparently healthy.

Physical examination findings are notable for a laceration on the right thenar eminence that is 2 cm long and 0.5 cm deep. The wound is partially crusted over with blood, with a small amount of serosanguinous discharge. The surrounding tissue is erythematous, hot, and exquisitely tender. There are two red streaks ascending the lower half of his anterior forearm. There is full range of motion without discomfort in any of the digits or the wrist of his right upper extremity. Neurologic examination of the hand reveals normal findings, and Allen’s test result is normal.

The following laboratory data are found: white blood cell count, 15,000/mm 3, with a differential count of 75% polymorphonuclear leukocytes, 5% band forms, 17% lymphocytes, 2% monocytes, and 1% eosinophils. His serum chemistry values are normal. A radiographic study of the hand


Case Studies

reveals no evidence of a foreign body or subcutaneous emphysema. Samples of the discharge and blood are sent for culture.

Cellulitis right hand. Will start patient on Cephalexin 500 mg q 6 hours and instructed patient to elevate arm when possible. Will see patient back after he finishes the antibiotic in 10 days, sooner if condition does not respond or worsens.

ICD-10-CM code(s): ________________________________________

Case 40History of Present Illness: Jim comes in complaining of a wooden splinter lodged beneath his left fifth fingernail, sustained at 4 p. m. yesterday. He is a carpenter and works construction. He was at work yesterday when the injury occurred. He attempted to remove it with tweezers at home, but was unsuccessful. He is requesting we attempt to remove this for him.

The patient states his last tetanus shot was 3 years ago.

Social History: Patient is married and is a nonsmoker and lives with his wife.

Physical Examination VITAL SIGNS: Temp and vital signs are all within normal limits. GENERAL: The patient is a pleasant elderly white male who is sitting on the stretcher in no acute distress. EXTREMITIES: Exam of the left fifth finger shows a 6- to 7-mm splinter lodged beneath the medial aspect of the nail plate. It does not protrude beyond the end of the nail plate. There is no active bleeding. There is no edema or erythema of the digit tip. There is no damage to the nail plate. Flexion and extension of the DIP joint is intact. The remainder of the hand is unremarkable.Treatment: I did attempt to grasp the end of the splinter with splinter forceps, but it is brittle and continues to break off. To better grasp the splinter, will require penetration beneath the nail plate, which the patient cannot tolerate due to pain. Consequently, the base of the digit tip was prepped with Betadine, and just distal to the DIP joint, a digital block was applied with 1% lidocaine with complete analgesia of the digit tip. I was able to grasp the splinter and remove this. No further foreign body was seen beneath the nail plate and the area was cleansed and dressed with bacitracin and bandage.

Assessment: Puncture wound with foreign body of the left fifth fingernail (wooden splinter).

Plan: Patient was urged to clean the area b.i.d. with soap and water and to dress with bacitracin and a Band-Aid. If he notes increasing redness, pain, or swelling, he was urged to return for re-evaluation.

ICD-10-CM code(s): ________________________________________

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