A Guided Approach to Intermediate and Advanced Coding (Lame, Young) - Chapter 8.docx

A GUIDED APPROACH TO INTERMEDIATE AND ADVANCED CODING TEST BANK CHAPTER 8: ADVANCED INPATIENT HOSPITAL CODING Directions: Code the following cases for inpatient facility purposes using ICD-10-CM and PCS codes. Calculate the MS-DRG. Identify the Principal vs. Secondary diagnoses and procedures. Use external cause codes when appropriate. Do NOT code procedures that are captured by the facility chargemaster. Secondary diagnoses and procedures do NOT need to be sequenced in any particular order. Enter “None” when no code is required. If more than one occurrence of a procedure is required, report the code with “x 2” “x 3” etc. 1. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 70-50-77 Age: 53 Gender: Male Length of Stay: 2 Days Service Type: INPATIENT Discharge Status: To Home Diagnosis/Procedure: Idiopathic Dilated Cardiomyopathy DISCHARGE SUMMARY PATIENT NAME: HUGH ACUTE ADMISSION DATE: 06-23-XX DISCHARGE DATE: 06-25-XX DISCHARGE DIAGNOSIS: 1. Idiopathic dilated cardiomyopathy, uncertain etiology. 2. Left bundle branch block. 3. Normal coronary arteries and normal hemodynamics. PROCEDURES: Cardiac catheterization. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old male admitted for evaluation of grossly abnormal Thallium test. LABORATORY DATA: Glucose 106, BUN 11, creatinine 1.1, liver function tests are all normal, albumin 4.2, sodium 141, potassium 4.8, cholesterol 166, triglycerides 122, iron 82. White count 6900, hemoglobin 17.2, MCV 95, platelets 136,000. Resting MUGA ejection fraction is performed. This shows an ejection fraction of 47%. HOSPITAL COURSE: The patient is admitted to the hospital and taken to the cardiac catheterization lab. The patient's hemodynamics showed right atrial pressure 4, pulmonary artery 32/14, pulmonary capillary wedge is 6, cardiac output is 6.5, pulmonary vascular resistance is 186, and oximetry is unremarkable. Coronary arteries are all perfectly normal. There is no mitral regurgitation. Left ventricle is quite dilated. Ejection fraction angiographically is 46%. All walls are hypokinetic except for the anterobasilar wall, which is normal. This is felt to be due to an idiopathic cardiomyopathy with normal hemodynamics. A resting MUGA scan was obtained as a baseline. The patient was discussed with Dr. XYZ. The patient was discharged on 12/19 to be admitted on 12/19/xx to USA Hospital for myocardial biopsy. DISCHARGE MEDICATIONS: Enteric aspirin 5 grains once a day and Capoten 12.5 mg 1½ tablets q 12 hours. He is to follow up with me in a couple of weeks. _____________________________ DR HEART, M.D. HISTORY AND PHYSICAL PATIENT NAME: HUGH ACUTE ADMISSION DATE: 06-23-XX CHIEF COMPLAINT: Abnormal thallium treadmill. Admit for heart catheterization. HISTORY OF PRESENT ILLNESS: The patient is a 38-year-old white male receiving primary care with a grossly abnormal—thallium treadmill test. Admitted now for heart catheterization. The patient really has minimal symptoms. He presented to the healthcare system recently for a complete physical just to make sure that everything was going fine. Dr. Know noted that the patient was having some fatigue and that he had a left bundle branch block. After discussing the case with Dr. Who, a thallium treadmill test was ordered which was quite abnormal as noted below. ALLERGIES: None known. MEDICATIONS: None. SOCIAL HISTORY: The patient works in a potato cellar doing fairly manual labor. The patient smoked two packs of cigarettes daily for 30 years stopping 2 weeks ago. The patient is adopted and has no knowledge of his blood relatives. MEDICAL HISTORY: He notes no exertional chest discomfort, neck discomfort, etc. of any type. He says that his exertional capacity and his exertional dyspnea is worse than it was 10 years ago, but feels that it is the same as it was 3 months ago and that it is the same as it was about a year ago. Apparently, he had an upper respiratory infection with productive cough, runny nose, sneezing, etc. this fall, but feels that he recovered satisfactorily from that. He does recall several episodes of epigastric discomfort manifest as a pressure sensation lasting perhaps a day at a time. He says he ignored it and it went away, and wondered whether he might have some gallbladder trouble. This never seemed to particularly get worse with exertion. The patient has no orthopnea, PND, or edema. He has used two pillows on his bed at night under his head for a long time. He has occasional heart racing but no lightheaded spells, near syncope, or syncope. There is no history of hypertension, hyperlipidemia, diabetes, congenital heart disease, rheumatic fever, heart murmur, or MI. REVIEW OF SYSTEMS: His general review of systems in detail is unremarkable. His only surgery is minor surgery on his knee. He does not use alcohol at all and never has. He uses one caffeinated beverage a day. He has no GI distress. He denies history of drug abuse, eye problems, cancer liver disease, emphysema, thyroid problems, gout, asthma, hay fever, hives, migraine headaches, TIA's, stroke, deep venous thrombosis, pulmonary embolism, kidney stones, etc. PHYSICAL EXAMINATION: GENERAL: BP 128/94, pulse 96, respirations distension. LUNGS: Clear. HEART: S1, S2 within normal limits with no murmurs, gallops, or rubs. ABDOMEN: Unremarkable. SKIN: Is warm and dry. Temp 97.9. NECK: No jugular venous distension. EXTREMITIES: There is no peripheral edema. ELECTROCARDIOGRAM: Complete left bundle branch block, with frequent PVC's. Axis is +90°. Borderline right atrial enlargement. EXERCISE THALLIUM TEST 06-21-XX The patient exercised 5 minutes 37 seconds on a Bruce Protocol elevating his heart rate to 178 (107% predicted maximum), and blood pressure to 174/84. He was stopped because of fatigue. The patient's heart rate increased rapidly with exercise and at the end of 3 minutes of exercise, his heart rate was already 165. At the end of 2 minutes off exercise, it was 157. He remained in left bundle branch block throughout and there- were no significant ST changes and no arrhythmias. He had no chest discomfort. The images showed a dilated left ventricle with hypoperfusion of the anterior wall, septal wall, and posterior wall. There was some redistribution of the anterior and anteraseptal aspects of the heart. There was no redistribution of the inferior aspect. ECHOCARDIOGRAM: 06-21-XX is technically limited, but shows severely reduced left ventricular function with normal chamber dimensions. Left atrium is at 3.9cm E point to septal separation is 1.4. ASSESSMENT: 1. High risk thallium scan with reduced IV function on echocardiogram inpatient with left bundle branch block and no symptoms. 2. Unknown family history. 3. Heavy smoking history. PLAN: Admit for heart cath. _________________________ DR. HEART, M.D. CARDIAC CATHETERIZATION LABORATORY PATIENT NAME: HUGH ACUTE PROCEDURE REPORT: PROCEDURE: Right and left heart catheterization, selective coronary angiography and left ventriculography. PROCEDURE NOTE: The patient is brought to the cardiac catheterization lab, and the right inguinal area is prepped and draped in the usual manner. Using Seldinger technique, both the right femoral artery and right femoral vein are cannulated, and sheath introducers are placed in each vessel. All catheter manipulations are done using a guidewire and under fluoroscopic control. A fiberoptic Swan-Ganz catheter is positioned in the right heart. A pigtail catheter is positioned in the ascending aorta. Hemodynamic pressure measurements are-made. The aortic valve is crossed in a retrograde manner. Hemodynamic pressure measurements are made. Thermodilution cardiac output is measured. Oximetry is measured in the right and left heart. The Swan-Ganz catheter is removed. Left ventriculography is performed in the RAO projection and is recorded on 35 mm cineangiographic film. The catheter is then pulled back across the aortic valve while pressure measurements are being made. The catheter is then exchanged over a guidewire for a Judkin's left coronary catheter, and left coronary cineangiography is performed in multiple projections in the usual manner. The catheter is then exchanged over a guidewire for a Judkins right catheter, and right coronary cineangiography is performed in the usual manner. At the conclusion of the case, hemostasis is obtained after catheters were pulled. There are no complications. HEMODYNAMIC FINDINGS: Right atrial pressure mean is 4 mm. of mercury. X and Y descent appear to be normal. The right ventricular end diastolic pressure is equal to the left ventricular end diastolic pressure. These two pressure waveforms are superimposed throughout diastole. Pulmonary artery pressure is 32/14, mean 21. Pulmonary capillary wedge mean is 6, with a normal V wave. Left ventricular pressure is 125/, 8. Aortic pressure is 125/65, mean 86. There is no gradient across the mitral valve during diastole or across the aortic valve during systole. Thermodilution cardiac output is 6.46 liters per minute. Systemic vascular resistance is 1015. Pulmonary vascular resistance is 186. Oximetry on blood samples shows saturation as follows: pulmonary artery 65%, right ventricle 64%, right atrium 64.7%, vena cavae 65%. Room air blood gas in the left ventricle 7.45, P02 62, PCO2 37, Bicarb. 26, Saturation 89%. LEFT VENTRICULOGRAM: There no mitral regurgitation. The anterobasilar wall moves normal. All other walls of the ventricle are hypokinetic. The left ventricle is moderately dilated, with an end diastolic volume of 321 cc's (upper limits of normal for his body surface area is 257 cc's). Ejection fraction is measured on several beats and ranges between 42 and 52%. CORONARY ANGIOGRAPHY: The coronary arteries are perfectly smooth and within normal limits. The LAD gives rise to a moderate sized first diagonal branch and a moderately large second diagonal branch. There is a large bifurcated ramus intermedius branch. There are two moderately large posterolateral branches of the circumflex. The right coronary artery gives rise to the posterior descending artery and one posterolateral branch. CONCLUSIONS: 1. Normal coronary arteries. 2. Dilated hypocontractile left ventricle with no mitral regurgitation. 3. Normal hemodynamics and cardiac output. 4. Normal oximetry. 5. Mild resting hypoxia. This picture is consistent with an idiopathic dilated cardiomyopathy. ______________________________ DR. HEART, M.D. ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: I42.0 SDx: I44.7, Z87.891 ICD-10-PCS procedure code(s): PPx: 4A023N8 SPx: B211YZZ, B215YZZ MS-DRG: 287 2. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 77-50-77 Age: 76 Gender: Male Length of Stay: 6 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Hemoptysis Fiberoptic bronchoscopy with biopsy DISCHARGE SUMMARY PATIENT: JARED INPATIENT RECORD NUMBER: 77-50-77 ADMITTED: 06-15-XX DISCHARGED: 06-21-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Hemoptysis. Hypertension. Atelectasis. PROCEDURE: Fiberoptic bronchoscopy x 2 with biopsy. HISTORY OF THE PRESENT ILLNESS: The patient is a 76-year-old white male admitted to the hospital with hemoptysis. The patient states that approximately three weeks ago, he had the onset of hemoptysis associated with clear sputum. This was not accompanied by chest pain, fever, or change in his chronic mild dyspnea. He did not have any pedal edema, PND, or orthopnea associated with it. He was given prescriptions for Lasix and Erythromycin when a chest x-ray report returned suggestive of possible congestive heart failure and/or pneumonia. He states that since then, his hemoptysis has significantly decreased though it is still present in the mornings. He is having difficulty feeling tired all the time but has not had any difficulty with sleep per se. There is no prior history of pneumonias and no prior history of CHF. He relates that he had an echocardiogram yesterday, results of which are unknown. There is no known TB exposure. The patient was born and raised here in this state. HOSPITAL COURSE: The patient was admitted and bronchoscopy was performed to evaluate hemoptysis and rule out carcinoma. Left lower lobe was collapsed, probably secondary to the left hemidiaphragm paralysis. There were no other endobronchial lesions. It should be noted that saturation by oximeter was 85% before the start of the procedure and before any sedative mediations were given. On day two of hospitalization, the patient was given another bronchoscopy with biopsies to work up possible atelectasis. Prior to the second bronchoscopy the patient was noted to have multifocal PVCs on the monitor before starting the procedure. The right sided tracheal bronchial tree was characterized by prominent changes of chronic inflammation. This was most impressive in the left lower lobe. The left lower lobe orifice was narrowed by extrinsic compression. The left lower lobe segmental orifices were markedly narrow due to extrinsic compression. Neither the brush nor the transbronchial biopsy forceps could be passed into the posterior or lateral segmental orifices. Endobronchial biopsies, brushings and washings were obtained from the left lower lobe segmental orifices. DISCHARGE PLANS: The patient was provided home oxygen, prn. Inhaler prescription was provided along with instructions. The patient is to follow up in the office in 2 days. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 06-21- xx 856 HISTORY AND PHYSICAL PATIENT: JARED INPATIENT RECORD NUMBER: 77-50-77 ADMITTED: 06-15-XX DISCHARGED: 06-21-XX PHYSICIAN: DR. ALEX, M.D. HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old white male admitted to the hospital with hemoptysis. The patient states that approximately 3 weeks ago, he had the onset of hemoptysis associated with clear sputum. This was not accompanied by chest pain, fever, or change in his chronic mild dyspnea. He did not have any pedal edema, PND, or orthopnea associated with it either. He was given prescriptions for Lasix and Erythromycin when a chest x-ray report returned suggestive of possible congestive heart failure and/or pneumonia. He states that since then, his hemoptysis has significantly decreased though it is still present in the mornings. He is having difficulty feeling tired all the time but has not had any difficulty with sleep per se. There is no prior history of pneumonias and no prior history of CHF. He relates that he had an echocardiogram yesterday, results of which are unknown. There is no known TB exposure. CURRENT MEDICATIONS: Cardene 20 mg, 1 tid, Lasix 20 mg, 1 qid. SOCIAL HISTORY: The patient quit smoking 30 years ago after 30 years of one pack per day. He was an engineer with the railroad for much of his working career. He did some work for a total of about 9 months between 1939 and 1940 in a backroom where there was much asbestos work being done and he feels that it was aerosolized. PAST MEDICAL HISTORY: He has known of high blood pressure for 2 to 3 years. His only prior surgery was an eye removal after an accident recently. FAMILY HISTORY: Father died of cancer, one brother died of an MI and another brother died of cancer. REVIEW OF SYSTEMS: Negative for kidney disease. Patient has known previous heart disease, phlebitis, rheumatic fever, hepatitis, liver disease, or peptic ulcer disease. PHYSICAL EXAM: VITAL SIGNS: BP is 180/100 and pulse is 80. HEENT: Unremarkable with a normal oropharynx. NECK: Supple without adenopathy or thyromegaly. CHEST: Has Velcro type rales at the right base. There is dullness where the left lung base should be. There are only a very few rales above that region. There are no wheezes heard after bronchodilator. ABDOMEN: Soft without tenderness, masses, or hepatosplenomegaly. EXTREMITIES: Without clubbing, cyanosis or edema. LABORATORY DATA: Room air blood gas obtained on the third hospital day, pH 7.45, PO2 58, PCO2 38. CBC and serum chemistries were within normal limits. Spirometry today shows a severe decrease in FVC which is partly related to air trapping. There is at least mild obstruction. There was a 53% improvement in FVC after Atrovent treatment. Chest x-rays are reviewed from one month ago and today. Those from one month ago showed dense interstitial infiltrate in the right lung predominant in the mid and lower lung region. There is some subsegmental atelectasis at the left base above his elevated left hemidiaphragm. The chest x-ray report from that time notes that this is probably old and was suggested on a previous upper GI. The right hilum, I believe is bulky. The heart is enlarged. Film today shows the vast majority of the infiltrate in the right base has resolved. The right hilum remains bulky in appearance. IMPRESSION: Hemoptysis. Resolving right lower lobe infiltrate suggest probable pneumonia. There may also be some interstitial lung disease associated with asbestos exposure, as there is persistence of rales on exam. Congestive heart failure. I am concerned; however, about the bulky appearance of the right hilum and that this may have been a post obstructive pneumonia. Furthermore, the hemoptysis is persisting. Chronic obstructive pulmonary disease and restrictive defect secondary to elevated hemidiaphragm. As the patient is only very mildly symptomatic with dyspnea and noticed no symptomatic improvement Atrovent inhaler is prescribed two puffs q 4 hours on a prn basis. PLAN: Bronchoscopy rule out endobronchial neoplasm. DR. ALEX, M.D. Electronically signed by Dr. Alex, 06-15-xx, 3345 OPERATIVE REPORT PATIENT: JARED INPATIENT RECORD NUMBER: 77-50-77 DATE OF SURGERY: 06-15-XX SURGEON: DR. ALEX, M.D. PREOPERATIVE DIAGNOSIS: Hemoptysis. POSTOPERATIVE DIAGNOSIS: 1. Hemoptysis, probably secondary to pneumonia. 2. Possible chronic hypoxemia. OPERATIVE PROCEDURE: Fiberoptic bronchoscopy. INDICATION: This 76-year-old white male had the onset of hemoptysis approximately 3–4 weeks ago. A chest x-ray revealed a right lower lobe infiltrate, left diaphragm paralysis, and signs of possible congestive heart failure. He was started on Erythromycin and Lasix with subsequent gradual tapering in the amount of hemoptysis. For the week prior to today, he has had only one episode. The chest x-ray showed interval improvement but the right hilum was felt to be enlarged. He is a former smoker and because the hemoptysis persisted for such a long period of time bronchoscopy was indicated to rule out endobronchial abnormality. DESCRIPTION: The P20 fiberoptic bronchoscope was passed via nasal approach. The upper airway was normal. The tracheal bronchial tree was remarkable for quite prominent diffuse changes of chronic inflammation with linear striations. The segmental orifices of the left lower lobe were collapsed, probably secondary to the left hemidiaphragm paralysis. There were no other endobronchial lesions. It should be noted that saturation by oximeter was 85% before the start of the procedure and before any sedative mediations were given. IMPRESSION: Hemoptysis, probably secondary to pneumonia. Possible chronic hypoxemia. DR. ALEX, M.D. Electronically signed by Dr. Alex, 06-15-xx, 3345 OPERATIVE REPORT PATIENT: JARED INPATIENT RECORD NUMBER: 77-50-77 DATE OF SURGERY: 06-16-XX SURGEON: DR. ALEX, M.D. PREOPERATIVE DIAGNOSIS: Left lower lobe atelectasis. POSTOPERATIVE DIAGNOSIS: Left lower lobe atelectasis with abnormal endobronchial findings as described. OPERATIVE PROCEDURE: Fiberoptic bronchoscopy with endobronchial biopsies, brushings and washings left lower lobe segmental INDICATIONS: This 76-year-old white male was admitted with hemoptysis and is now being evaluated for atelectasis. CT scan of the chest showed some left lower lobe atelectasis. Follow up CT scan of the chest showed decrease in the size of the left lower lobe scan of the chest showed decrease in the size of the left lower lobe atelectasis which was felt to be possibly related to an elevated left hemi-diaphragm. Recent repeat follow up CT scan of the chest showed increase in the amount of left lower lobe atelectasis and an apparent pleural effusion associated with it. The patient has not had any new symptoms. He is felt to have probable asbestosis by his exposure history and finding pleural plaques and interstitial fibrosis on chest x-ray and CT scan. DESCRIPTION: The patient was noted to have multifocal PVCs on the monitor before starting the procedure and was therefore pre-medicated with 75 mg of Lidocaine IV. He was also given 0.5 mg of Versed IV as well as Robinul 0.3 mg IM. A P-20 fiberoptic bronchoscope was passed via nasal approach. The upper airway was felt to be within normal limits. The right sided tracheal bronchial tree was characterized by prominent changes of chronic inflammation. This was most impressive in the left lower lobe. The left lower lobe orifice was narrowed by extrinsic compression. The left lower lobe segmental orifices were markedly narrow due to extrinsic compression. Neither the brush nor the transbronchial biopsy forceps could be passed into the posterior or lateral segmental orifices. Endobronchial biopsies, brushings and washings were obtained from the left lower lobe segmental orifices. These areas were quite friable. The patient tolerated the procedure without apparent difficulty and only occasional PVCs were noted during the procedure. Saturation on room air post procedure is 91%. PATHOLOGY REPORT RESULTS: Bronchial mucosal fragments, left lower lobe, showing no diagnostic features. DR. ALEX, M.D. Electronically signed by Dr. Alex, 06-16-xx, 3345 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: J98.11, SDx: R04.2, J44.9, I50.9, I10, J18.9, J84.1, Z87.891, Z77.090, Z82.49, Z80.9 ICD-10-PCS procedure code(s): PPx: 0B9J8ZX SPx: 0BJK8ZZ x2, 0BJL8ZZ x2 MS-DRG: 205 3. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 72-50-77 Age: 79 Gender: Female Length of Stay: 5 Days Service Type: INPATIENT Discharge Status: To Home Diagnosis/Procedure: Colon Cancer. Partial Colectomy. DISCHARGE SUMMARY PATIENT NAME: Cassandra Inpatient RECORD NUMBER: 72-50-77 ADMISSION DATE: 05-02-xx DISCHARGE DATE: 05-7-xx PHYSICIAN: DR. TONY, M.D. DISCHARGE DIANOSIS: 1. Colon cancer, specifically adenocarcinoma. PROCEDURES: 1. Partial colectomy. HOSPITAL SUMMARY: The patient is a 79-year-old white widow who was admitted to the hospital for workup of some abdominal pain. She had been having trouble for several weeks and been going downhill. Her appetite had been bad. She was brought into the hospital initially for workup and part of that workup included a barium enema, which showed a constricting annular lesion of the colon. At that point, the patient was seen by an internist, who evaluated the patient. After transfusing some blood to build up her hematocrit, she was taken to surgery electively and underwent a partial colectomy for treatment of this condition. Her postoperative course was excellent and she was able to be discharged temporarily to a nursing home to continue her recovery. Please see full operative dictation for complete details of the surgical procedure. _____________________________ Tony Surgeon, M.D. HISTORY AND PHYSICAL PATIENT NAME: Cassandra Inpatient RECORD NUMBER: 72-50-77 ADMISSION DATE: 05-02-xx DISCHARGE DATE: xx-xx-xx PHYSICIAN: DR. TONY, M.D. CHIEF COMPLAINT: Abdominal pain and fullness. HISTORY OF PRESENT ILLNESS: This is a 79-year-old white female who has been ill for the past several days with abdominal pain and bloating, even some diarrhea on the day prior to admission. She thought that maybe she had just had the stomach flu, but when she did not get better, she was brought to the office for an examination. At that time, the patient looked pale and she was admitted to short stay initially for work up. The patient had been known to be anemic recently and been taking some iron pills for that. She denied any blood in the stool or any blood in the urine or any place else. PAST MEDICAL HISTORY: 1. History of anemia. 2. She has a history of obstructive hydrocephalus that was due to an arachnoid cyst and she did undergo ventriculo-peritoneal shunt placement for that. 3. She also has a history of psoriasis. PAST SURGICAL HISTORY: She has had a hysterectomy, appendectomy and the shunt placement as mentioned above for the hydrocephalus. She also had a laminectomy for spinal stenosis. I believe the shunt placement in her head was in inserted earlier in the year. MEDICATIONS: Besides some topical ointment for psoriasis and iron for the anemia, she is not on any medications. ALLERGIES: No known drug allergies. SOCIAL HISTORY: She does not smoke or drink. She used to smoke, but quit about 30 years ago. The patient is a widow. She lost her husband to heart problems. REVIEW OF SYSTEMS: She has lost some weight over the past several months. She is not sure exactly how many pounds. She has been progressively getting weaker in the past several months as well. PHYSICAL EXAMINATION GENERAL: She presents as a pale appearing white elderly female. She is in no acute distress. VITAL SIGNS: Normal with a temperature of 98.6°F. HEENT: Negative, excepting pale mucous membranes of the eyes and oral mucoua. NECK: Supple with no masses. CHEST: Lungs are clear. CARDIOVASCULAR: Heart is regular. No murmurs or gallops. BREASTS: Not examined at this time. ABDOMEN: Soft. It is tender to palpation in all quadrants. Definite mass is felt to palpation. EXTREMITIES: Extremities show no cyanosis, clubbing or edema. INITIAL IMPRESSION: 1. Abdominal pain of unknown cause. I have a suspicion that this patient may have some sort of occult malignancy with the weight loss and anemia, specifically colon cancer. PLAN: Admission and workup of these problems. DR. TONY, M.D. Electronically authenicated by Dr. Tony, 05-07-xx 6789 OPERATIVE REPORT PATIENT NAME: Cassandra Inpatient RECORD NUMBER: 72-50-77 OPERATION DATE: 05-02-xx SURGEON: Dr. Tony, M.D. PREOPERATIVE DIAGNOSIS: 1. Adenocarcinoma of the hepatic flexure of the colon. 2. Cholecystitis and cholelithiasis. POSTOPERATIVE DIAGNOSIS: 1. Adenocarcinoma of the hepatic flexure of the colon. 2. Cholecystitis and cholelithiasis. PROCEDURE PERFORMED: Right hemi colectomy, cholecystectomy. ANESTHESIA: General. DESCRIPTION OF PROCEDURE: The patient was brought to the operating room with IV infusing. Preoperative antibiotics administered. General anesthesia was induced. Nasogastric tube and Foley catheter were inserted. The abdomen was prepped with Betadine sterilely. Skin marker was used to outline a transverse upper abdominal incision beginning in the right mid abdomen laterally and extending toward the epigastrium. Skin incision was made with a #10 blade and carried through subcutaneous tissue to expose fascia. Bleeding was controlled with electrocautery. Oblique muscles were divided with electrocautery as is the rectus muscle exposing the peritoneum. The peritoneum was identified and entered. Manual and visual exploration of the abdominal cavity reveals tumor in the hepatic flexure of the colon without obvious extension into pericolonic tissues. The gallbladder is chronically inflamed and contains stones. Retractor was positioned. With traction on the fundus of the gallbladder, the peritoneum overlying the hepato-duodenal ligament is incised. By blunt dissection, the cystic duct is skeletonized, doubly clipped and divided. Similarly, the cystic artery is bluntly dissected, doubly clipped and divided. With traction on the divided duct, the gallbladder is dissected from the liver bed with the use of the electrocautery. Specimen is submitted for pathologic evaluation. Pack was placed into the liver bed and removed after approximately 10 minutes and there is no evidence of bleeding from this surface. Attention is then turned to the colon section. The lateral peritoneal reflection is incised with Metzenbaum scissor and the colon is reflected medially. By blunt dissection, the mesentery is elevated from the retroperitoneum. The right ureter is identified and preserved. Point of division is chosen in the distal ileum and a GIA stapler is passed and fired. Similarly, a point in the mid transverse colon is chosen for division and a GIA stapler passed and fired. Peritoneum overlying the mesentery is incised with the Metzenbaum scissor. Mesentery is then divided between clamps and 20 silk ties and the right colon is submitted for pathologic evaluation. Area of dissection is irrigated and examined carefully for hemostasis prior to anastomosis. The small bowel was juxta opposed against the transverse colon and secured in place with 0 muscular 2–0 silk-interrupted suture. An enterotomy is made in the small bowel and colon and the GIA stapler is passed and fired forming the anastomosis. Enterotomy is then closed in two layers. The first layer is a running 3–0 chromic full thickness suture and the second is an interrupted 0 muscular 3–0 silk suture. Mesentery is then closed using a running 2-0 Vicryl suture. The area of dissection is examined carefully for hemostasis prior to closure following correct sponge, needle and instrument counts the abdomen is closed. Posterior fascia is approximated using a running suture of #1 Vicryl. The anterior rectus sheath and external oblique muscles are approximated using a running #1 Vicryl suture reinforced at intervals with #1 Prolene. Subcutaneous layer was irrigated and examined for hemostasis. Scarpa's fascia was then approximated using interrupted 2–0 Vicryl suture. Skin is approximated with skin stapler. Dry sterile dressings were applied. The patient tolerated the procedure well and was transferred to the recovery room in stable condition. DR. TONY, M.D. Electronically authenicated by Dr. Tony, 05-07-xx 6789 PATHOLOGY REPORT PATIENT NAME: Cassandra Inpatient RECORD NUMBER: 72-50-77 OPERATION DATE: 05-02-xx SURGEON: Dr. Tony, M.D. SPECIMEN SUBMITTED 1. Gallbladder. 2. Right side of colon and terminal ileum. TISSUE REPORT HISTORY: CA of colon. Gross 2: Right side of the colon including attached terminal ileum and right side of colon without the appendix. The terminal ileum is 10 cm in length. It has a fairly smooth but granular serosal surface, a firm wall, a mucosa that is folded and light green. The segment of colon is 35 cm in length, includes cecum, ascending and transverse segments of the colon. In the ascending portion of the colon there is a somewhat pedunculated irregular polyp 55 x 40 x 30 mm; the surface is folded and light grey but the center is superficially ulcerated, granular and light grey. The cut section of this lesion reveals it appears to be confined to the mucosa although in the center there is a suggestion that the lesion infiltrates into the muscle coat. 5 cm distal to this polypoid lesion in the region of the transverse segment of the colon there is a 7 cm in length 4 cm in width circumferential penetrating and perforating polypoid tumor that extends to the muscle coat and into the serosal adipose tissue. The margins around the area of penetration are thickened, granular, polypoid, grey to red infected. On cut section of the mesentery in this region, it also infiltrates into the attached mesenteric adipose tissue. 6 cm distal to this lesion and approximately 3 cm from the distal resection margin there is an additional pedunculated polyp 15 x 5 x 3 mm. The cut section of the mesentery reveals eleven firm light gray lymph nodes several of which appear to be obviously replaced by firm light gray tumor. The lymph nodes are more or less discrete, the largest 15 mm in diameter. Sections of terminal ileum one block. Sections of the most proximal polypoid lesions. Sections of large penetrating lesion. Sections of most distal polypoid lesion. Sections of mesenteric lymph nodes. Gross 1. Gallbladder 7 x 4 x 2 cm. The surface of the gallbladder is smooth appears to be slightly thickened. The mucosa is green; the lumen contains about 10 and numerous mulberry green gallstones, the largest 5 mm in diameter. MICROSCOPIC: 1. Gallbladder reveals changes of chronic cholecystitis. 2. Normal terminal ileum tubulovillous adenoma the center of which has infiltrated into the muscle coat. 3. The most proximal polypoid lesion reveals a well-differentiated adenocarcinoma. Lesion 5 cm distal to the polypoid area reveals a poorly differentiated adenocarcinoma composed of malignant epithelial cells having vacuola and cytoplasm arranged in cords and nests or solid sheets. This shows evidence of having provoked a rather prominent desmoplastic response extensively infiltrating the muscle coat into the serosal surface and the attached mesenteric adipose tissue. The mesenteric adipose tissue immediately adjacent to the area where the lesion has infiltrated into the mesenteric adipose tissue reveals areas thickened by proliferated fibrous connective tissue containing lymphocytes. No definite involvement in these areas can be identified. 4. The most distal polyp reveals a benign tubulovillous adenoma. 5. The sections of the 11 mesenteric lymph nodes 2E reveal, basically hyperplastic lymph nodes without any evidence of metastases. Sinusoids contain plasma cells or a few giant cells. DIAGNOSIS: Cholecystitis, chronic. 1. Calculus, multiple right side of colon and terminal ileum. 2. Adenocarcinoma, poorly differentiated, proximal portion, transverse segment of colon. 3. Lesion infiltrates into the serosal surface and the mesenteric adipose tissue. 4. Adenocarcinoma, well-differentiated, mucosa, ascending portion of the colon. 5. Adenocarcinoma infiltrates into the superficial muscle coat. 6. Polyp, adenomatous or tubular type, distal portion, transverse segment of the colon. 7. Lymph nodes, hyperplastic, multiple (11), mesentery, right side of the colon. 8. Segment, terminal ileum, normal. COMMENT: This 79- year-old female in the proximal transverse segment of the colon has a 7 cm in length 4 cm in width circumferential penetrating and perforating polypoid lesion that extended right to the serosal surface and the adipose tissue. On microscopic examination, this is a poorly differentiated adenocarcinoma of colonic mucosa. 11 adjacent lymph nodes were isolated and are free of metastases. In addition proximal to this adenocarcinoma there was a 55 mm polyp in the ascending portion of the colon the center of which reveals development of an early well-differentiated adenocarcinoma of colonic origin infiltrating into superficial muscle coat. Pathological stage: T3 No MO, modified Duke’s 82. DR. PAT, M.D. Electronically authenticated by Dr. Pat, M.D. 05-03-xxx 4322 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: C18.3 SDx: K80.18, D64.9, Z87.891 ICD-10-PCS procedure code(s): PPx: 0DTF0ZZ SPx: 0FT40ZZ MS-DRG: 330 4. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 76-50-77 Age: 31 Gender: Male Length of Stay: 1 Day Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Left Inguinal Hernia Herniorrhaphy DISCHARGE SUMMARY PATIENT: WALLACE INPATIENT Record Number: 76-50-77 ADMITTED: 06-03-XX DISCHARGED: 06-04-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Left inguinal hernia. PROCEDURE: Herniorrhaphy. HISTORY OF THE PRESENT ILLNESS: : The patient is a 31-year-old Caucasian male who was in his usual state of health until approximately 1–2 weeks prior to admission at which time he developed severe pain in his left groin following some heavy lifting. He noticed that he had swelling in his groin and presented for evaluation with a diagnosis of hernia being made. HOSPITAL COURSE: Hospital course was uneventful with the patient returning from the recovery room in good condition. The patient was watched overnight and was afebrile on the morning of discharge. Surgical site was stable with no operative complications. Patient was in good condition on discharge to home. DISCHARGE PLANS: Discharge to home with prescription for pain medication. Patient is to follow diet and activity instructions until follow with me in the office in three weeks. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 06-21- xx 8567 HISTORY AND PHYSICAL PATIENT: WALLACE INPATIENT Record Number: 76-50-77 ADMITTED: 06-03-XX DISCHARGED: 06-04-XX PHYSICIAN: DR. ALEX, M.D. CHIEF COMPLAINT: Left inguinal hernia. HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old Caucasian male who was in his usual state of health until approximately 1–2 weeks prior to admission at which time he developed severe pain in his left groin following some heavy lifting. He noticed that he had swelling in his groin and presented for evaluation with a diagnosis of hernia being made. PAST MEDICAL HISTORY: Usual childhood disease. Medical diseases: He has asthma, no other medical diseases. No previous surgery. Patient denies any injuries, allergies, medications or transfusions. DRUG ALLERGIES: None known. MEDICATIONS: None. FAMILY HISTORY: Mother and father alive and well. No history of familial diseases. SOCIAL HISTORY: He is a student. He is unmarried. Does not drink or smoke. REVIEW OF SYSTEMS: Negative. PHYSICAL EXAMINATION: Demonstrates a well-nourished, well-developed 31-year-old Caucasian male who appears to be approximately his stated age. HEENT: Normal. NECK: Supple. Trachea midline. Thyroid is normal. There are no nodes, masses or bruits in the neck. The supraclavicular and infraclavicular regions are clear. THORAX: There is normal anterior posterior diameter to the thorax. BREASTS: Undeveloped without masses. LUNGS: Clear to auscultation and percussion. CARDIOVASCULAR: Heart regular rhythm without murmur. S1, S2 are normal. No S3, S4. ABDOMEN: Soft. Bowel sounds are normal. There is a left inguinal hernia. There are no other megaly, mass, hernias bruits. SPINE: Straight. No CVA tenderness. RECTAL: Not done. EXTREMITIES, NEUROLOGICAL and VASCULAR EXAMINATIONS: Normal. IMPRESSION: Left inguinal hernia with repair. DR. ALEX, M.D. Electronically signed by Dr. Alex, M.D., 06-03-xx, 124 OPERATIVE REPORT PATIENT: WALLACE INPATIENT RECORD NUMBER: 76-50-77 DATE OF SURGERY: 06-03-XX SURGEON: DR. ALEX, M.D. PREOPERATIVE DIAGNOSIS: Left inguinal hernia. POSTOPERATIVE DIAGNOSIS: Left indirect inguinal hernia. OPERATIVE PROCEDURE: Repair of left inguinal hernia with high ligation of the sac and Bassini reconstruction of the floor. ANESTHESIA: General. DESCRIPTION: After adequate sedation, the patient was brought to the operating room and placed in the supine position on the operating table. Anesthesia was induced with intravenous Pentothal, endotracheal tube was passed and the patient was maintained on endotracheal anesthesia. After obtaining proper anesthesia, the patient was prepped and draped in the usual fashion. A standard left groin incision was accomplished, carried down through subcutaneous tissue. The external oblique was divided in line with its fibers; the cord structures were carefully freed up and protected with a Penrose drain. The cremasteric muscle was incised and a large sac identified. This was very thin-walled and had the appearance of being extremely acute. The sac was carefully freed up from the surrounding tissues, twisted and high ligation accomplished with 0 silk followed by a 2–0 silk suture ligature. The sac was excised. A relaxing incision was performed in the usual fashion. Cremasteric was removed from the end of the conjoined tendon. The conjoined tendon was sutured to the shelving edge of Poupart’s with interrupted 0 Marceline. The wound was irrigated with antibiotics and injected with Marcaine after which the external oblique was repaired with a continuous 3–0 Silk. The wound was then again irrigated with antibiotics after which the dermis was approximated with continuous 3–0 Vicryl and the epidermis with Steri-Strips. Sterile dressings were applied. The patient was allowed to wake up, was extubated and taken to recovery where he arrived in satisfactory condition. DR. ALEX, M.D. Electronically signed by Dr. Alex, M.D., 06-03-xx, 1242 PATHOLOGY REPORT PATIENT: WALLACE INPATIENT RECORD NUMBER: 76-50-77 DATE OF SURGERY: 06-03-XX SURGEON: DR. ALEX, M.D. OPERATION: Left inguinal hernia repair GROSS DESCRIPTION: Submitted from the left inguinal region are portions of purplish-tan, membranous, fibrous connective tissue, which together measure approximately 4.5 cm. Representative portions are submitted for examination. MICROSCOPIC DESCRIPTION: Sections reveal fibrovascular connective and adipose tissue. Portions of the tissue have a sac-like configuration with the lumen lined by mesothelium cells. DIAGNOSIS: Hernia sac without significant features. DR. PAT, M.D. Electronically signed by Dr. Pat, M.D., 06-04-xx, 2245 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: K40.90 SDx: None ICD-10-PCS procedure code(s): PPx: 0YQ60ZZ SPx: None MS-DRG: 352 5. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 79-50-77 Age: 36 Gender: Female Length of Stay: 5 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Insulin reaction Renal failure Diabetes Mellitus, Type II, long term insulin dependence Permanent catheter right internal jugular Removal peritoneal dialysis catheter DISCHARGE SUMMARY PATIENT: RAINEY INPATIENT RECORD NUMBER: 79-50-77 ADMITTED: 12-19-XX DISCHARGED: 12-24-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSES: 1. Insulin reaction. 2. Renal failure. 3. Diabetes mellitus, Type II. OPERATIONS/ PROCEDURES: 1. Permanent catheter right internal jugular. 2. Removal of peritoneal dialysis catheter. DISCHARGE MEDICATIONS: 1. Ceftin 250 mg bid. 2. Reglan. 3. Prilosec. 4. Iron. 5. Procardia. HISTORY: This patient is a 36-year-old woman who was admitted because of insulin reaction, nausea, and vomiting. She has renal failure. The plan was to admit her for placement of a permanent access catheter for dialysis and she had an insulin reaction with a blood sugar of 17 Dextrostrip prior to the admission. She was given Glucagon in the unit. An IV was started in the emergency room. She was given D5 and water. She had been experiencing nausea and had not eaten as well as probably was necessary as an outpatient. LABORATORY DATA: EKG showed T-wave inversion inferiorly and ST segment depression, stable and on specific. Urine culture and blood culture at the time of this dictation reveals no growth. SMAC showed a creatinine of 7.0, BUN 34, glucose 208, uric acid 5.9, alk. phos. 283, SGOT 238, LDH 294, total protein 4.7, albumin 1.4 grams, sodium 130, potassium 3.5, chloride 95 millimoles per liter, cholesterol 111, the rest of the SMAC was normal. Hemoglobin on admission had been 10.8, hematocrit 32.5, white count 4.1K with a normal differential. Platelets were adequate. The hematocrit was 17.8 the day before discharge. She was given one unit of packed red blood cells. Chest x-ray showed significant improvement on 12–21 of the pleural effusion she had had on previous films. HOSPITAL COURSE: The patient was admitted to the hospital with an insulin reaction and given intravenous glucose as above after she had had an insulin reaction in the field and glucagon had been given. She received Prilosec and Reglan intravenously initially and then the Reglan was changed to oral. I gave it 2 hours before the meal. This seemed to enable her to eat and retain food. She had a slight fever. Cultures of the urine and blood were obtained but no growth was present so far. She had been on Cipro as an outpatient. I did not think any catheters were infected nor was there any evidence of peritonitis from the peritoneal dialysis. The peritoneal dialysis catheter had been removed during this hospital stay and another catheter placed in the right upper chest. I treated her empirically with Fortaz after obtaining cultures. The morning of Dec 24th, she was very anxious to go home for Christmas. I told her that I recommended she stay in the hospital to take the intravenous antibiotics and continue to monitor things as we had had such a difficult time controlling the blood sugar ranging from nearly 900 one day to below 50 the next. She, however, was well oriented, understood the situation, and definitely wanted to leave the hospital for Christmas with her family. DISPOSTION: She was discharged on 12/24. She would take her usual medications at home except would d/c the Cipro and take Ceftin 250 mg bid. She would continue Reglan, Prilosec, Iron and Procardia. Dialysis would be again on Thursday and then again on Saturday. Follow up in about one week in the office. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 12-26-xx 5568 HISTORY AND PHYSICAL PATIENT: RAINEY INPATIENT RECORD NUMBER: 79-50-77 ADMITTED: 12-19-XX DISCHARGED: 12-24-XX PHYSICIAN: DR. ALEX, M.D. CHIEF COMPLAINT: Severe renal failure secondary to very brittle diabetes mellitus, Type II, with long-term treatment with insulin. HISTORY OF PRESENT ILLNESS: Severe renal failure secondary to very Type II diabetes mellitus, long-term treatment with insulin. This patient with renal failure was previously on peritoneal dialysis. She is not tolerating peritoneal dialysis due to very low total protein and albumin. This patient needs a more permanent hemodialysis access. We will place a temporary subclavian or temporary jugular catheter. The patient is being admitted to the hospital at this time for placement of dialysis catheter via one of the internal jugular sites. DRUG ALLERGIES: None known. PERSONAL MEDICAL HISTORY: Otherwise unremarkable. Most recently, she had a severe episode of hypoglycemia. The patient subsequently went home and was admitted to the hospital the morning surgery was to be accomplished having been found by her mother cold and with a very low blood sugar. She was brought to the emergency room and taken straight to the floor where she responded. FAMILY HISTORY: Paternal grandmother with diabetes mellitus. REVIEW OF SYSTEMS: Otherwise unremarkable. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 87.5. Blood pressure of 153/86, pulse of 85, respirations 16. GENERAL: The patient felt cold. HEENT/NECK: Otherwise unremarkable. LUNGS: Clear to auscultation and percussion. CARDIOVASCULAR: Regular sinus rhythm. ABDOMEN: Benign. EXTREMITIES: Unremarkable. IMPRESSION: Severe renal failure secondary to very brittle diabetes mellitus, Type II, long-term dependence on insulin. RECOMMENDATIONS: Placement of perm-cath through one of the internal jugular sites. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 12-26-xx 5568 OPERATIVE REPORT PATIENT: RAINEY INPATIENT RECORD NUMBER: 79-50-77 SURGERY DATE: 12-19-XX DISCHARGED: 12-24-XX PHYSICIAN: DR. ALEX, M.D. PREOPERATIVE DIAGNOSIS: Chronic renal failure in a very brittle diabetic, unable to tolerate peritoneal dialysis because of loss of protein and albumin. POSTOPERATIVE DIAGNOSIS: Chronic renal failure in a very brittle diabetic, unable to tolerate peritoneal dialysis because of loss of protein and albumin. OPERATIVE PROCEDURE: Cut down placement of permanent catheter right internal jugular and removal of peritoneal dialysis catheter. ANESTHESIA: General endotracheal. DESCRIPTION: The patient was taken to the operating room having been put to sleep, endotracheal tube in place. She had Betadine prep of the entire neck, jaw, and upper thorax down to the nipples. She also had prep of the left lower quadrant around the permanent catheter. She had a sterile drape in both areas. Attention was turned towards placing the permanent catheter. Initially, a transverse incision was made in the skin line, distal third of the neck on the right, transverse fashion and carried down through platysma muscle. Hemostasis was obtained with a Bovie. Flaps were developed inferiorly and superiorly, sufficient to allow muscle-splitting incision through anterior body sternocleidomastoid muscle. The dissection was carried straight down. Deep fascia of the neck was encountered and there was marked scarring in this location. The patient had a previous temporary dialysis catheter long term on this side. The carotid artery was palpated and adjacent to the artery just laterally. The lateral border of the scarred, whitish colored wall of the internal jugular vein was identified. With gradual dissection over the top of this, we were able to isolate the jugular vein from the carotid artery, taking care not to injure the vagus nerve. The vein was dissected free from a distance of approximately 2 cm, vascular tape was passed without difficulty. Dissection was prolonged because of the dense tissue in this region. We were able to get around this without entering the vessel. A #4–0 Prolene vascular purse string was then placed in Trendelenburg position. Ends were placed inferiorly on the purse string so that it could be tied directly down on the vein. The catheter was then inserted after what was felt to be the appropriate length was selected. Incision was then made so a #36 French catheter could be inserted through skin tunnel located below the clavicle on the right side and brought through a portion of the muscle to allow for adequate bend without kinking. Once this was accomplished, the internal jugular was lifted anteriorly with the Bakke pickups and a #15 blade was used to make an opening in the vein. The vein, as indicated, was scarred and sclerosed, however, an opening was made sufficient to allow placement of the catheter without difficulty. In the process, approximately 25 cc of blood was lost. The purse string was then tied down. There was a small leak on the superior aspect and stick tie of #4–0 Vascular Prolene was then sewed to secure this. X-ray was obtained and catheter was seen in the part of the superior vena cava, and it was pulled out approximately 2 cm so that the pledget regressed still just inside the skin. This was accomplished and wound was irrigated. A #2–0 Vicryl was used to approximate the deep fascial layer of the neck and platysma muscles also approximated with #2–0 Vicryl. A #4–0 Vicryl was used subcuticular and Steri-Strips were used on the skin. The wound was dressed and tegaderm was placed over the catheter where it came out of the skin. Attention was then turned towards the peritoneal dialysis catheter. Dressings were removed off of this location and cut so we could get down to where the catheter had been inserted just above the iliac crest on the left. The incision for insertion was well above where the catheter went. It was a good 6 cm above where the catheter failed to go. A ¼-inch incision was made directly over where we thought the catheter was inserted on the lateral border of the rectus muscle. Hemostasis was obtained with a Bovie after incision was made in the skin. With blunt dissection, we were able to go down and identify the catheter, go through the abdominal wall musculature. This was identified just lateral to the edge of the rectus. The catheter was then grasped. It was cut in this location and the pledget was placed near the skin, was removed after making a 1 ½ cm incision along the tract of the catheter down to its junction with the peritoneum. This was identified. The catheter was pulled back after it was removed and there adherent omentum on the catheter in this location. This was transected after being clamped with a small clamp, the end of the omentum tied off with #2-0 silk, and the omentum was tucked back into the abdominal cavity. The edges of the peritoneum and fascia, which were hypertrophied, were grasped with clamps and three #3-0 stick ties of #0 Vicryl were used to close this opening in the peritoneum. The wound was irrigated and the fascial layer anteriorly was then used to approximate the subcuticular layer and #4-0 Prolene used to run and close skin. Accu-Chek prior to coming back to the ICU approximately 30 minutes before case was over was 230. The patient had no complications during surgery. She was sent to the recovery room with stable vital signs. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 12-26-xx 5568 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: E11.649 SDx: R11.2, E11.22, N18.6, Z79.4 ICD-10-PCS procedure code(s): PPx: 05HY33Z SPx: 0WPG00Z MS-DRG: 983 6. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 73-50-77 Age: 34 Gender: Female Length of Stay: 2 days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Repeat cesarean section. DISCHARGE SUMMARY PATIENT: LUCINDA INPATIENT RECORD NUMBER: 73-50-77 ADMITTED: 07-24-XX DISCHARGED: 07-26-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Repeat cesarean section at term with single liveborn infant. HISTORY OF THE PRESENT ILLNESS: This is a 34-year-old Gravida 2, Para 1, female who presents at 39 weeks gestation with previous cesarean section, 1 at term for elective repeat cesarean section. The history and physical is unchanged from the office record as updated today. HOSPITAL COURSE: The patient was taken to the surgical suite where a repeat cesarean section was performed. A viable 8 pound 8 ounce male infant was delivered demonstrating Apgars of 8 at one minute and 9 at five minutes. The baby was taken to the nursery in good condition. The remainder of the hospital course was uneventful with mom and baby recovering nicely. Mom was discharged on day two of hospitalization to home with no complications of surgery and feeling well. DISCHARGE PLANS: Discharged to home with cesarean wound care instructions. The patient is to return to the office for normal surgical checkup and then at 6 weeks. Instructions to seek help immediately if fever or other complications occur. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 06-21- xx 8567 HISTORY AND PHYSICAL PATIENT: LUCINDA INPATIENT RECORD NUMBER: 73-50-77 ADMITTED: 07-24-XX DISCHARGED: 07-26-XX PHYSICIAN: DR. ALEX, M.D. HISTORY OF PRESENT ILLNESS: This is a 34-year-old Gravida 2, Para 1, female who presents at 39 weeks gestation with previous cesarean section x’s 1 at term for elective repeat cesarean section. The history and physical is unchanged from the office record as updated on 10-02-xxxx, and a copy of which appears in the chart. PHYSICAL EXAMINATION: HEENT/NECK: Examination is clear. The thyroid is normal. LUNGS: Chest is clear to auscultation. CARDIOVASCULAR: Heart is regular rate and rhythm with no murmurs. ABDOMEN: Reveals a 45 cm fundus with good fetal heart tones. EXTREMITIES: Clear. GENITORECTAL: Deferred. IMPRESSION: Previous cesarean section at term. PLAN: After a thorough discussion earlier in the pregnancy in regard to vaginal birth after cesarean section, its attendant risks and concerns as well as the clinical impression of a small mid pelvis outlet, the patient understands her options and alternatives and I feel freely gives an informed consent for a repeat cesarean section. She presents at this time for this procedure. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 07-22-xx, 6543 OPERATIVE REPORT PATIENT: LUCINDA INPATIENT RECORD NUMBER: 73-50-77 DATE OF SURGERY: 07-24-xx SURGEON: DR. ALEX, M.D. ASSISTANT SURGEON: DR. BILLIE, M.D. PREOPERATIVE DIAGNOSIS: Previous cesarean section at term. POSTOPERATIVE DIAGNOSIS: Previous cesarean section at term. OPERATIVE PROCEDURE: Repeat low cervical transverse cesarean section. COUNTS: Instrument and sponge count were correct. ESTIMATED BLOOD LOSS: 600 cc. DESCRIPTION: After a satisfactory level of spinal anesthesia was obtained the patient as prepped and draped in the supine position in the usual manner for abdominal surgery. The abdomen was entered by excision into the old Pfannenstiel scar and a low cervical transverse cesarean section performed. A viable 8 pound 8 ounce male infant was delivered demonstrating Apgars of 8 at 1 minute and 9 at 5 minutes when evaluated by the attending nursing personnel. The placenta and membranes were removed and the endometrium bluntly curetted with the surgeons fingers and covered with a moist lap. The endometrium was then closed with cutaneous 0 Vicryl. The myometrium was imbricated using 0 Vicryl and vertical Limberg suture technique with good hemostasis. The serosa was then closed with continuous 2–0 Vicryl and all free blood and clot removed from the pelvic cavity bilaterally. The anterior peritoneum was closed with cutaneous 2–0 Vicryl. The fascial remnants in the midline were approximated with interrupted 0 Vicryl and the fascia itself was closed with continuous 0 Vicryl using 2 sutures overlapped in the midline. The subcutaneous dead space was closed in multiple layers of 3–0 Vicryl and 4–0 Vicryl subcuticular was used to approximate the skin edges. Steri-Strips and a sterile dressing applied. The procedure was terminated. The patient tolerated this procedure well and was transferred to the recovery room awake and in satisfactory condition. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 07.25.xx 3211 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: O34.211 SDx: Z3A.39, Z37.0 ICD-10-PCS procedure code(s): PPx: 10D00Z1 SPx: None MS-DRG: 766 7. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 82-50-77 Age: 81 Gender: Female Length of Stay: 2 Days Service Type: Inpatient Discharge Status: To Long-Term Care Diagnosis/Procedure: Severe Peripheral Venous Cellulitis Lower Extremities, Bilateral. DISCHARGE SUMMARY PATIENT: MYRA INPATIENT RECORD NUMBER: 82-50-77 ADMITTED: 03-15-XX DISCHARGED: 03-17-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSIS: Severe peripheral venous cellulitis with 4+ edema lower extremities (bilateral). HISTORY: This patient is an 81-year-old female admitted because of severe edema of her lower extremities and developing leg ulcers bilaterally. LABORATORY DATA: SMAC showed glucose of 132, SGPT 29, albumin 3.2, cholesterol 258. The rest of the SMAC was normal. Urinalysis was physiologic. Hemoglobin 13.6, hematocrit 40.7, white count was 4,800 with a normal differential. Platelets were adequate. Red blood cell morphology was essentially normal. HOSPITAL COURSE: The patient was admitted to the hospital to treat bilateral leg 4+ pitting edema and weeping infections of the sacrum and of both feet. Cultures of both the sacrum and feet were performed with cultures returning positive for staphylococcus aureus, methicillin susceptible, and Group A streptococcus. The patient was started on IV Tetracycline and Lasix. Edema of her feet cleared rapidly with simple elevation and two doses of Lasix. After discussion with the family, it was felt that long-term care placement was the most appropriate place to care for this patient. DISCHARGE PLANS: Patient was transferred to the local long-term care facility with orders to remain mostly at bed rest with the legs elevated along with an order for heat lamp to the sacral area qid. Tetracycline treatment will continue as ordered for the next 5 days with review at that time. I suspected mild depression in the patient with orders to watch for increasing signs or symptoms with intervention as needed. The patient will be followed in the long-term care facility. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 03-18-xx 856 HISTORY AND PHYSICAL PATIENT: MYRA INPATIENT RECORD NUMBER: 82-50-77 ADMITTED: 03-15-XX DISCHARGED: 03-17-XX PHYSICIAN: DR. ALEX, M.D. CHIEF COMPLAINT: Severe peripheral venous cellulitis with 4+ edema lower extremities (bilateral). HISTORY OF PRESENT ILLNESS: This patient is an 81-year-old Caucasian female who lives alone and recently has lost her husband. The patient’s daughter states that activities of daily living are accomplished only because of her help to the patient. The daughter checks on her mother three times a day to assure meals, baths, and general living activities. It is noted that the patient chooses to sleep in her chairs in the living room and not in her bed. The patient’s legs reveal 4+ pitting edema and very swollen as her feet are down all day. She has weeping infections of both the sacrum and of both feet. The patient is alert and awake but does not seem interested in helping herself get better. Home health has been seeing the patient on a bi-weekly basis but has stated that that the patient really cannot be managed at home any longer and needs to have other living arrangements for her own safety and health. She has been on no other medications. ALLERGIES: She is allergic to Penicillin. Does not tolerate Codeine. MEDICATIONS: Tetracycline. Hormone shot and Thyroxin. FAMILY HISTORY: Family history of heart disease, diabetes, skin cancers. PAST HISTORY: History of stroke eight months ago with resultant gait ataxia. She has had an appendectomy, total abdominal hysterectomy, a T&A, varicose vein operations and hemorrhoidectomy. She has had an adenomatous polyp with villous features removed from her colon in September. She has had skin cancers removed from her legs. Hypothyroidism. REVIEW OF SYSTEMS: At this time, the patient has no complaints. She is a very reluctant patient and does not cooperate for examination. Patient denies any physical problems at this time. PHYSICAL EXAMINATION: GENERAL: Patient is awake, alert and noncooperative. There is weeping lesions of both feet and sacrum. HEENT: Normocephalic without lesions. Fundi normal. She is wearing her dentures and does wear glasses. Hearing is good. LUNGS: Clear to auscultation and percussion. No breast masses are noted. HEART SOUNDS: Normal. Rhythm is regular. ABDOMEN: Palpation of the abdomen reveals no masses. Bowel sounds are normal. There are no bruits. PELVIC and RECTAL: Not attempted with this noncooperative patient. There is an area of skin breakdown over the sacrum and both feet are 4+ edematous with weeping from the dorsum of the feet. ADMITTING DIAGNOSIS: 1. Severe edema with secondary infections of wounds of the sacrum and feet. Cerebrovascular disease with previous stroke. Hypothyroidism on replacement therapy. PLAN: Admit for treatment of edema and weeping lesions of feet and sacrum. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 03-15- xx 8567 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: L03.115 SDx: L03.116, L03.317, B95.61, R60.0, E03.9, I67.9, I69.393, Z88.0 , Z79.890, F32.9 ICD-10-PCS procedure code(s): PPx: None SPx: None MS-DRG: 603 8. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 81-50-77 Age: 32 Gender: Male Length of Stay: 2 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Foreign Body Left Ankle DISCHARGE SUMMARY PATIENT: PATRICK INPATIENT RECORD NUMBER: 81-50-77 ADMITTED: 10-15-XX DISCHARGED: 10-17-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSIS: Healing fracture left ankle with retained foreign body implant. PROCEDURE(S): Removal of foreign body implant from left ankle (K-wire and screw). HISTORY OF THE PRESENT ILLNESS: This 32-year-old male patient is admitted for removal of hardware from his left ankle. History reveals that the patient sustained a fracture of his left ankle 4 years ago. The patient sustained the ankle fracture after jumping off a train while working in the rail yard and turned his ankle. The patient has been symptom free until recently when started having some pain and problems with his ankle. He presents now requesting to have the hardware removed from the healed ankle. LABORATORY DATA: We obtained blood for CBC, Chem screen, PT, PTT and a urinalysis. We did an EKG, which shows a normal sinus rhythm. There-are no acute ST or T-wave changes and a chest x-ray was also done which is not particularly remarkable, other than borderline cardiomegaly HOSPITAL COURSE: The patient underwent removal of hardware with no complications and was discharged on the morning of day 2. DISCHARGE PLANS: The patient was discharged with prescription for pain medication as needed and to return for post op checkup as scheduled or call to be seen immediately for any sign of infection or complication. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 10-21-xx 4887 HISTORY AND PHYSICAL PATIENT: PATRICK INPATIENT RECORD NUMBER: 81-50-77 ADMITTED: 10-15-XX DISCHARGED: 10-17-XX PHYSICIAN: DR. ALEX, M.D. CHIEF COMPLAINT: Foreign body of the left ankle. HISTORY OF PRESENT ILLNESS: This 32-year-old male patient is admitted for removal of hardware from his left ankle. History reveals that the patient sustained a fracture of his left ankle 4 years ago. The patient sustained the ankle fracture after jumping off a train while working in the rail yard and turned his ankle. The patient has been symptom free until recently when started having some pain and problems with his ankle. He presents now requesting to have the hardware removed from the healed ankle. He is admitted to the hospital now for surgery. DRUG ALLERGIES: No known drug allergies. MEDICATIONS: None. SURGERIES: History of open reduction and internal fixation of the left ankle 4 years ago. MEDICAL ILLNESS: Patient is a healthy appearing male with no known medical illnesses at this time. REVIEW OF SYSTEMS: HEENT: No history of headaches, blurred vision, double vision or loss of vision. No history of frequent sore throats, nose bleeds or neck pain. CHEST: No shortness of breath, diaphoresis, palpitation or chest pain. ABDOMEN: No history of nausea, vomiting, diarrhea or weight loss. GU: No history of dysuria, frequency, hesitancy, urgency or hematuria. PHYSICAL EXAM: GENERAL: Alert and cooperative male who appeared to be in no acute distress. HEENT: Head was normocephalic. Pupils are equal and react to light and accommodation. Extraocular muscles are intact. Oropharynx and nasopharynx are within normal limits. NECK: Supple. No evidence of any lymphadenopathy. CHEST: Clear. HEART: Regular rate and rhythm. No murmurs. ABDOMEN: Soft, no masses. GU: That of a normal male. ADMITTING DIAGNOSIS: Healed left ankle fracture with retained foreign body. PLAN: The patient will be admitted to the hospital for removal of hardware from his left ankle. Procedure, sequelae, alternatives and complications were discussed and the patient wishes to proceed. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 10-15-xx 4887 OPERATIVE REPORT PATIENT: PATRICK INPATIENT RECORD NUMBER: 81-50-77 SURGERY DATE: 10-15-XX SURGEON: DR. ALEX, M.D. PREOPERATIVE DIAGNOSIS: Healing fracture left ankle with retained foreign body implant. POSTOPERATIVE DIAGNOSIS: Healing fracture left ankle with retained foreign body implant. OPERATIVE PROCEDURE: Removal of foreign body implant from left ankle (K-wire and screw). ANESTHESIA: General DESCRIPTION: The patient was taken to the operating room and placed on the operating table in a supine position. after he was adequately anesthetized using general inhalation anesthesia , tourniquet was placed high on the groin of the left leg, which was elevated and prepped with Betadine and properly placed sterile drapes. Small incision was made over the medial malleolus at the site of the previous incision. It was carried down through the subcutaneous tissues. Using fluoroscopy, the K-wire and the screw were identified, the deltoid ligament was sharply split, and the K-wire and the screw were removed. The split in the deltoid was then repaired using 2–0 Vicryl simple interrupted sutures. The skin was dosed using 3–0 Ethilon vertical mattress sutures. Sterile dressing was placed on the patient and the patient returned to the recovery room in satisfactory condition. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 10-15-xx 4887 RADIOLOGY REPORT PATIENT: PATRICK INPATIENT RECORD NUMBER: 81-50-77 DATE: 10-15-XX PHYSICIAN: DR. ALEX, M.D. LEFT ANKLE HISTORY: Healed left ankle fracture status post hardware removal. LEFT ANKLE: Two images have been exposed with the C-arm demonstrating no residual screws or pins in the medial malleolus. Calcifications are present between the distal tibia and fibula from previous damage to the interosseous ligaments. The medial malleolar fracture has healed in anatomical alignment. DR. RAY, M.D. Electronically authenticated by Dr. Ray, M.D., 10-15-xx 2254 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: T84.84XA SDx: S82.52XS, W13.8XXS ICD-10-PCS procedure code(s): PPx: 0SPG04Z SPx: None MS-DRG: 494 9. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 80-50-77 Age: 77 Gender: Female Length of Stay: 5 Days Service Type: Inpatient Discharge Status: To Home Health Diagnosis/Procedure: Peritrochanteric Right Hip Fracture Mild Hypertension Total Right Hip Arthroplasty DISCHARGE SUMMARY PATIENT: JOY INPATIENT RECORD NUMBER: 80-50-77 ADMITTED: 09-15-XX DISCHARGED: 09-20-XX PHYSICIAN: DR. ALEX, M.D. DISCHARGE DIAGNOSIS: Peritrochanteric right hip fracture. Mild hypertension. PROCEDURE(S): Total right hip arthroplasty. HISTORY OF THE PRESENT ILLNESS: This is a 77-year-old white female who presented to the emergency room with complaint of pain in the right hip after falling down at her home. The patient slipped on the kitchen floor. She was not able to get up because of her complaints of right hip pain. She did not have any significant shortening of the right lower extremity but is very minimally externally rotated. LABORATORY DATA: We obtained blood for CBC, chem screen, PT, PTT and a urinalysis. We did an EKG, which shows a normal sinus rhythm. There-are no acute ST or T-wave changes and a chest x-ray was also done which is not particularly remarkable, other than borderline cardiomegaly. HOSPITAL COURSE: The patient was admitted to the hospital for definitive treatment of the right hip fracture in the form of a total hip arthroplasty. The patient was sent to the orthopedic floor and was provided immediate relief with routine fractured hip care orders. The patient was given pain medication in form of Mepergan 2 cc intramuscularly. IV was started and Foley catheter inserted in anticipation of emergent surgery and prior to being taken to the operating room. Patient tolerated the procedure well and was able to start physical therapy on day one after the surgery. Patient progressed slowly over the next couple of days but showed constant improvement. On day five, the patient was discharged to home with order for home health and physical therapy. DISCHARGE PLANS: The patient will receive home health and physical therapy on a twice-weekly basis for six weeks. After 6 weeks, the patient will be re-evaluated. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 09-21-xx 445 HISTORY AND PHYSICAL PATIENT: JOY INPATIENT RECORD NUMBER: 80-50-77 ADMITTED: 09-15-XX DISCHARGED: 09-20-XX PHYSICIAN: DR. ALEX, M.D. CHIEF COMPLAINT: Pain in the right hip after falling down at her home. The patient slipped on the kitchen floor. HISTORY OF PRESENT ILLNESS: This 77-year-old white female was admitted following -a fall when she slipped on her apartment kitchen floor and fell down and injured her right hip. She was brought by ambulance from her home to the Emergency Room where she was evaluated. X-rays were obtained that showed a nondisplaced peritrochanteric fracture of the right hip. She was admitted and placed in Buck's traction and will be scheduled for surgery at the earliest convenience. DRUG ALLERGIES: Percoset. MEDICATIONS: Daily vitamin and Wytensin for hypertension. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Lives alone with close neighbors and three children who all live in the same area and visit her regularly. PAST MEDICAL HISTORY: She has a history of mild hypertension and previous cholecystectomy as well as a melanoma removed from her left lower eyelid 10 years ago. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 98.6, pulse 102, respirations 16, and blood pressure is 155/70. GENERAL: This is a healthy and quite alert white female for age, no acute distress. HEENT/NECK: Edentulous, has a skin graft in the left lower eyelid consistent with her melanoma surgery, wears glasses, otherwise within normal limits. CARDIOVASCULAR: Clear. Heart slightly enlarged PMI at the anterior axillary line, no murmurs, regular rate and rhythm. ABDOMEN: Protuberant, soft, well-healed abdominal scar. EXTERMITIES: Right leg in a slightly externally rotated position. Distally pulses are palpable. There is no significant pitting edema. GENITORECTAL: Genitalia and rectal deferred. NEUROLOGICAL: Oriented times four. Cranial nerves II through XII intact. Deep tendon reflexes are symmetrical except the right leg, which was not tested. . DIAGNOSTIC STUDIES: X-rays were obtained that showed a nondisplaced peritrochanteric right hip fracture. IMPRESSION: Peritrochanteric right hip fracture. RECOMMENDATIONS/PLAN: At this time, the patient is admitted for definitive care of her right hip. I discussed surgical versus conservative- management and because the patient is very active, she has opted for surgery. The patient is being admitted for a total hip arthroplasty. Risks of infection, pulmonary embolus, anesthetic risks, other treatment options and ramifications were discussed at length with the patient. She is understands these risks and wishes to proceed. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 09-15-xx 8876 OPERATIVE REPORT PATIENT: JOY INPATIENT RECORD NUMBER: 80-50-77 DATE OF SURGERY: 09-15-XX SURGEON: DR. ALEX, M.D. PREOPERATIVE DIAGNOSIS: Peritrochanteric right hip fracture. POSTOPERATIVE DIAGNOSIS: Peritrochanteric right hip fracture. OPERATIVE PROCEDURE: Total right hip arthroplasty, Ceramic-on-Polyethylene. ANESTHESIA: General. DESCRIPTION: After adequate sedation, the patient was brought to the operating room and placed in supine position on the operating table. After obtaining proper anesthesia, the patient was prepped and draped in the usual fashion for right hip arthroplasty. Incision was made along the posterior aspect of the right hip with the patient in a lateral decubitus position. The short external rotator muscles were released by incision from their insertion on the femur, exposing the joint capsule. The capsule was incised. The hip was then dislocated posteriorly. The femoral head was resected with a reciprocating saw. Osteophytes found around the rim of the acetabulum were removed with an osteotome. Acetabulum was then reamed out with power reamer exposing both subchondral and cancellous bone. The acetabular component was inserted with good result. The femoral canal was then prepared utilizing a hand reamer. A caliper was utilized to measure the femoral head size for replacement with appropriate component selected. The femoral shaft was prepared by enlarging the canal. The stem was secured into the femoral shaft and then pounded into place with an impactor. No complications were experienced and the stem secure. The femoral stem prosthesis was then reduced and repositioned. No allograft or auto graft was required. The external rotator muscles are reattached and the incision was sutured in multiple layers placement of four suction drains. Estimated blood loss was 340 cc. Autologous blood collection was done intraoperatively with transfusion of whole blood perioperative. Sponge and needle count were correct. Patient was sent to recovery in satisfactory condition. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 09-15-xx ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: S72.101A SDx: I10, W01.0XXA, Y92.010, Z88.5 ICD-10-PCS procedure code(s): PPx: 0SR904Z SPx: None MS-DRG: 470 10. INPATIENT HOSPITAL Health Record Face Sheet Record Number: 84-50-77 Age: 53 Gender: Male Length of Stay: 6 Days Service Type: Inpatient Discharge Status: To Home Diagnosis/Procedure: Atherosclerosis Coronary Arteries. Unstable Angina. Double Coronary Artery Bypass. DISCHARGE SUMMARY PATIENT: JED INPATIENT RECORD NUMBER: 84-50-77 ADMITTED: 06-15-XX DISCHARGED: 06-20-XX PHYSICIAN: DR. ALEX, M.D. DIAGNOSIS: Atherosclerosis coronary arteries with chronic total occlusion. Unstable angina. Congestive heart failure, combined systolic and diastolic, chronic. PROCEDURE: Coronary artery bypass graft x 2. HISTORY OF THE PRESENT ILLNESS: The patient is a 53-year-old male who presents with unstable angina of two hours duration in the emergency room. The patient was noted to be in congestive heart failure with impending probable infarction. The patient was admitted directly to the CCU. LABORATORY DATA: Glucose 106, BUN 11, creatinine 1.1, liver function tests are all normal, albumin 4.2, sodium 141, potassium 4.8, cholesterol 166, triglycerides 122, iron 82. White count 6900, hemoglobin 17.2, MCV 95, platelets 136,000. HOSPITAL COURSE: The patient was admitted to the CCU at the hospital. Workup revealed the patient to have atherosclerosis of the coronary arteries, unstable angina, with congestive heart failure in need of a double bypass. The patient underwent coronary artery bypass with resolution of angina. The patient tolerated the procedure well and was responding well to the CABG postsurgical clinical pathway. The patient was sitting up on the night of the surgery and standing the next morning. The patient progressed from that point and is very motivated to recover and manage his health. Patient was also treated for the congestive heart failure in the hospital and will be on medication for this diagnosis daily. DISCHARGE PLANS: The patient is to follow up with me in the office in one week or sooner if needed. Prescription for Capoten 12.5 mg 1 ½ tablets q 12 hours and Lasix 1 mg q daily. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 06-21- xx 8567 HISTORY and PHYSICAL PATIENT: JED INPATIENT RECORD NUMBER: 84-50-77 ADMITTED: 06-15-XX DISCHARGED: 06-20-XX PHYSICIAN: DR. ALEX, M.D. CHIEF COMPLAINT: Unstable angina. HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old male who presents with unstable angina of 2 hours duration in the emergency room. The patient was noted to be in congestive heart failure with impending probable infarction. The patient was admitted directly to the CCU. ALLERGIES: None known. MEDICATIONS: None. SOCIAL HISTORY: The patient is an automotive repair technician. The patient smokes one and a half packs of cigarettes daily for 30 years. Grandfather, paternal, died of myocardial infarction at age 64. MEDICAL HISTORY: Patient notes chest discomfort, neck discomfort, and arm discomfort typical of pre-infarction/unstable angina on and off for the last 2 months. The patient has also had an upper respiratory infection with productive cough, runny nose, sneezing, in the last month with no symptoms today. He does recall several episodes of epigastric discomfort manifest as a pressure sensation lasting perhaps a day at a time in the past months but states he ignored it and the pressure sensation and discomfort went away. The patient has no orthopnea, PND, or edema. He has occasional heart racing but no lightheaded spells, near syncope, or syncope. There is no history of hypertension, hyperlipidemia, diabetes, congenital heart disease, rheumatic fever, heart murmur, or MI. REVIEW OF SYSTEMS: His general review of systems in detail is unremarkable. His only surgery is minor surgery on his knee. He does not use alcohol at all and never has. He has no GI distress. He denies history of drug abuse, eye problems, cancer liver disease, emphysema, thyroid problems, gout, asthma, hay fever, hives, migraine headaches, TIA's, stroke, deep venous thrombosis, pulmonary embolism, kidney stones, etc. PHYSICAL EXAMINATION: GENERAL: BP 140/101, pulse 98, respirations distension. LUNGS: Clear. HEART: As previously noted, angina, rapid rate. ABDOMEN: Unremarkable. SKIN: Is warm and dry. Temp 97.9. NECK: Slight jugular venous distension. EXTREMITIES: There is no peripheral edema. ASSESSMENT: Unstable angina. Congestive heart failure, combined systolic and diastolic, chronic. Heavy, current smoking history. PLAN: Admit for cardiac workup and possible coronary artery bypass surgery. The risks, alternatives, risks and other options were explained to the patient. The patient wishes to proceed with the bypass surgery if indicated. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 06-15- xx 8567 OPERATIVE REPORT PATIENT: JED INPATIENT RECORD NUMBER: 84-50-77 SURGERY DATE: 06-15-XX DISCHARGED: 06-20-XX SURGEON: DR. ALEX, M.D. PREOPERATIVE DIAGNOSIS: 1. Atherosclerosis coronary arteries with chronic total occlusion. 2. Unstable angina. 3. Congestive heart failure, combined systolic and diastolic, chronic. POSTOPERATIVE DIAGNOSIS: 1. Atherosclerosis coronary arteries with chronic total occlusion. 2. Unstable angina. 3. Congestive heart failure, combined systolic and diastolic, chronic. OPERATIVE PROCEDURE: Coronary artery bypass graft x 2 using greater saphenous vein from aorta to right mid coronary artery and distal right coronary artery. ANESTHESIA: General. DESCRIPTION: The patient was taken to the operating room and placed on the operating table in a supine position. Patient was adequately anesthetized using general inhalation anesthesia with pulmonary and arterial artery monitoring and sterile prep of the surgical field, a sterile midline sternotomy was performed. The ascending aorta and right atrium was anatomically identified and preparatory purse-string sutures were placed in both the ascending aorta and right atrium. The next step in the procedure was to institute cardiopulmonary bypass with a single, two-stage venous uptake tube. Saphenous vein was harvested from the left leg using the endoscope. The aorta was clamped above the heart. Cardioplegia was affected with cold preserving solution pumped through the coronary arteries to stop the heart. The right coronary artery was identified with anatomical area chosen beyond the diseased portion and a longitudinal incision was cut in it. The proximal part of the vein was trimmed to the same length as the cut in the coronary artery and is cleaned off. Using 6–0 Prolene suture, end-to side anastomosis was created between the right mid coronary artery and the aorta. This was duplicated for the second opening and end-to-side anastomosis was performed from the aorta to the distal right coronary artery. The clamp on the aorta was released and following spontaneous contraction of the heart, cardiopulmonary bypass was discontinued. The patient was observed for a time with stable heart function. Approximation of the pericardium was then performed with hemostasis obtained. Sternum was approximated with surgical stainless steel parasternal wire. Fascia and skin was closed with Vicryl sutures. The patient tolerated the procedure well and was transferred to the recovery room in stable condition. DR. ALEX, M.D. Electronically authenticated by Dr. Alex, M.D., 06-15- xx 8567 ICD-10-CM diagnosis code(s): PDx_____________________ SDx _____________________ ICD-10-PCS procedure code(s): PPx_____________________ SPx_____________________ MS-DRG: _____________________ Answers: ICD-10-CM diagnosis code(s): PDx: I25.10 SDx: I25.82, I20.0, I50.42, Z72.0 ICD-10-PCS procedure code(s): PPx: 021109W SPx: 5A1221Z, 06CQ4ZZ MS-DRG: 236