1. The patient is a 26-year-old female who presents for follow up of left sided renal calculi. The patient was originally seen in the emergency room down state for left sided flank pain. She was found to have an obstructing renal calculi with CT stone protocol per the results. A culture was also done at her visit last week and grew beta hemolytic strep greater than 100,000 organisms. In the office today the patient continues to have colicky left sided flank pain, continued chills, nausea, and loss of appetite. She has no documented fevers and no vomiting. She has 8 days left of Ciprofloxacin. The patient is out of Vicodin.

Blood pressure is 140/70, weight is 101.36 kilograms. Heart regular rate and rhythm, no murmurs. Lungs are clear to auscultation bilaterally. Abdomen has positive bowel sounds times 4 quadrants. There is CVA tenderness and left lower quadrant pain on palpation. There is no guarding and no rebound tenderness. Skin is clean without rashes, erythema, or jaundice.

A/P 1. Urinary tract infection with beta hemolytic strep 2. Elevated blood pressure secondary to pain The patient will stop her Ciprofloxacin. A prescription for amoxicillin 850 mg p.o. b.i.d. times 7 days was given to her today. Vicodin 5/500 1 to 2 p.o. every 4 hours p.r.n. pain, #60 were given with no refills. The patient was encouraged to continue to strain her urine. She was also given encouragement to drink 2 liters of Coke.

ICD-10-CM-code(s) _________________________________

2. Operative Report

Preoperative Diagnosis:
Foreign body, right external ear canal.

Anesthetic:
General. TIME BEGAN: 1015 TIME ENDED: 1035

Postoperative Diagnosis:
Same.

Pathology Specimen:
None.

Operation:
Removal of foreign body using the microscope.

Date of Procedure: 05/12/08 TIME BEGAN: 1021 TIME ENDED: 1022

ICD-10-CM code(s) _________________________________

3. Chief Complaint: Chest pain.

History of Present Illness: I was asked to see Tom in consultation by Dr. Smith for the above complaint. He was in his usual state of health until last evening. He has a sudden onset of lower subxiphoid pain radiating to the posterior back. Subxiphoid region to the infrascapular region. He had some nausea accompanying it, but no actual emesis. He has a family history of sudden cardiac death in his father at roughly the same age. This concerned him and he presented to the Emergency Department. He has been evaluated and this is not felt to be cardiogenic in nature. An ultrasound has been obtained that shows changes consistent with acute cholecystitis.

Past Medical History:
1. Positive for gastroesophageal reflux disease
2. Hypertension
3. Gout.

Past Surgical History: Collarbone surgery.

Medications: Current medications as an outpatient include:
1. Diovan
2. Hydrochlorothiazide
3. Metoprolol
4. Allopurinol

Allergies: No known drug allergies.

Social History: Negative tobacco. Positive ethanol, one drink daily.

Family History: Positive for the above coronary artery disease in his father. Positive for diabetes mellitus.

Review of Systems: Eleven point review of systems with positives noted in the History of Present Illness. Additionally, anorexia. The rest of the 11 point review of systems is negative.

Physical Examination:
HEENT: Normal
NECK: Supple
CARDIOVASCULAR: Regular
LUNGS: Clear
ABDOMEN: Soft. There is tenderness in the right upper quadrant on deep palpation, but no actual Murphy’s sign is elicited.
GU: No inguinal hernia
EXTREMITIES: No edema
NECROLOGIC: No lateralizing signs

Diagnostic Study Results: Ancillary studies: Ultrasound as above is consistent with acute cholecystitis.

Assessment: Acute cholecystitis

ICD-10-CM code(s) __________________________________

4. History of Present Illness: I was asked by Dr. Smithers to see Mr. Jones in consultation for the above complaints. He reports that he was fine until yesterday, ate a bowl of fruit with onset suddenly afterwards of abdominal pain. It was mid-abdomen, sharp in nature. He reports he took some overthe- counter meds and hoped that this would alleviate the symptoms. He actually went golfing and after finishing 9 holes, he reports the pain was severe; he could not continue and he then subsequently presented to the emergency department. En route, he had an episode of nausea and emesis. This consisted primarily of the food substances, and he also had additional emesis in the emergency department and one this a.m. He reports no change in his bowel habits recently. He did have a formed bowel movement yesterday. He reports passing a small amount of flatus additionally. This a.m., he reports the pain is markedly improved. He also did have some nausea previously this a.m., but actually has a bit of an appetite at this point in time.

Past Medical History: Positive for hypertension, positive for coronary artery disease. Past Surgical History: Coronary artery bypass grafting
Medications: Lopressor, Altace, Lipitor and aspirin
Allergies: No known drug allergies
Social History: Negative for ethanol abuse. He denies tobacco use
Family History: Noncontributory
Review of Systems: Pertinent positives are noted in history of present illness. Additionally noted some chest pressure. The rest of the 11-point review of systems was negative.

Physical Examination
GENERAL: Comfortable appearing, middle-aged white male
HEENT: Sclerae are anicteric
NECK: Supple
CARDIOVASCULAR: Regular
LUNGS: Clear
ABDOMEN: Soft, mildly tympanic. There is a small umbilical hernia that is readily reducible. There is also diastasis recti present. Bowel sounds are hyperactive with occasional rushes. No organomegaly is noted. No masses are palpable. GENITOURINARY: No cough impulses
EXTREMITIES: Not edematous

Diagnostic Study Results: CT and abdominal films were reviewed. They do show evidence of a partial high-grade obstruction.

Assessement and Plan: Small bowel obstruction, this appears to be high-grade, etiology not completely defined.

ICD-10-CM code(s) ____________________________________

5. Postoperative Diagnoses:
1. Obstructive sleep apnea
2. Tonsillar hypertrophy
3. Pigmented lesion right temple

Procedure:
1. Uvulopalatopharyngoplasty
2. Tonsillectomy
3. Excision of pigmented lesion left temple measuring 9 mm in width and 2.4 cm in length

Anesthesia: General

ICD-10-CM code(s) _______________________________

6. Operative Report Procedure
Date: 05/12/xx

Surgeon: Dr. Smyther
Preoperative Diagnosis: Acute appendicitis
Postoperative Diagnosis: Acute appendicitis
Procedure Performed: Laparoscopic appendectomy
Anesthesia: General
Estimated Blood Loss: Minimal
Complications: None
Indications: The patient is a 50-year-old gentleman who presented to the emergency room with signs and symptoms of acute appendicitis. He has been brought to the operating room at this time for laparoscopic appendectomy. The risks and benefits were discussed and he wished to proceed.
Findings: The patient was found to have acute appendicitis without evidence of perforation.

ICD-10-CM code(s) __________________________________

7. Preoperative Diagnosis: Desire for sterilization.
Postoperative Diagnosis: Desire for sterilization.
Operation: Essure.
Anesthesia: IV sedation.
Gross Findings: Evaluation under anesthesia revealed normal sized and shaped uterus. No adnexal masses were palpated. Hysteroscopic visualization of the cervix revealed no lesion. Hysteroscopic visualization of the endometrial cavity revealed no lesion. The cavity was normal size, shape and contour.

ICD-10-CM code(s) _________________________________

8. Preoperative Diagnosis: Retained intrauterine device
Postoperative Diagnosis: Retained intrauterine device
Operation: 1. Evaluation under anesthesia. 2. Removal of intrauterine device Anesthesia: Laryngeal mask airway (LMA).
Findings: Normal ParaGard intrauterine device (IUD), not sent to pathology
Indication for Procedure: The patient is a 32-year-old female with a ParaGard intrauterine device IUD placed approximately 10 years ago. She presented to the office for a removal recently. Upon attempts in the office, the IUD string detached from the IUD Multiple attempts in the office utilizing polyp forceps and ultrasound guidance were unsuccessful in removing the IUD. Decision was made to bring the patient back for evaluation under anesthesia and removal.
Description of Operation: Complications: None. Disposition. Stable. Estimated blood loss: Less than 10 mL. After informed consent was obtained, the patient was brought back to the operative suite where adequate general anesthesia was obtained. The patient was then placed in dorsal lithotomy position and prepped and draped in a sterile fashion. A weighted speculum was placed inside the vagina, and the anterior lip of the cervix was grasped with a long Allis clamp. Upon examination after relaxation, it was noted that the IUD was in the lower uterine segment Utilizing polyp forceps, the IUD was able to be grasped at its base and removed from the uterus. Minimal bleeding was occurred. No hysteroscopy was necessary. Vaginal instruments were then removed.

The patient was then awoken from the general anesthesia and transferred to the recovery room in stable condition.

ICD-10-CM code(s) __________________________________

9. Female Age: 80-year-old patient presents today for pessary cleaning and fitting. Patient offers no complaints. Wt: 118 Exam: Ext Gen +BUS.WNL. Vag spec exam reveals no lesions. Pessary removed, scrubbed, vagina swabbed with Betadine, and pessary replaced. For F/U in ~ 4 months.

ICD-10-CM code(s) __________________________________

10. Preoperative Diagnoses:
1. Uncontrolled primary severe open-angle glaucoma, left eye
2. Pseudophakia, left eye

Postoperative Diagnoses:
1. Uncontrolled primary severe open-angle glaucoma, left eye
2. Pseudophakia, left eye

Procedure: 1. Attempted limbal-based trabeculectomy with mitomycin C and Express shunt under the scleral flap, left eye. 2. Open globe repair, left eye.

Anesthesia: Retrobulbar with monitored anesthesia care

After informed consent was obtained, the patient was brought to the operating room, and a retrobulbar block was performed using 5 cc of a 50/50 mixture of 4% lidocaine, 0.75% Marcaine, and added Wydase to obtain anesthesia and akinesia.

The patient was prepped and draped in usual sterile fashion for intraocular surgery. A lid speculum was placed to separate the lids of the left eye.

Under the operating microscope, a 6-0 Vicryl suture was placed through the peripheral superior clear cornea and was secured to rotate the globe inferiorly.

A superonasal limbal-based conjunctival flap was fashioned with Westcott scissors with the initial incision made at approximately 9 to 10 mm posterior to the limbus. The flap was dissected to the limbus, and at this point, an old superior limbal cataract wound was noted between the 11 and 12 o’clock position of the limbus. The wound appeared to be open, and aqueous did flow through this wound. At this point, the decision to not perform a trabeculectomy secondary to an open globe was made.

The old cataract superior limbal wound was closed with three interrupted 10-0 Nylon sutures. A #51 blade was used to enter the anterior chamber and balanced salt solution was used to inflate the chamber. The superior clear corneal wound was checked for leak. There was a small trickle and this was noted to be adequate for maintenance of the anterior chamber. The Tenon’s layer as well as the conjunctiva was then closed separately using a running 8-0 Vicryl suture on a BV needle. The wound was checked and found to be without leak. Furthermore, there was no apparent bleb that was formed secondary to the superior clear limbal wound. The pressure of the eye was then reassessed and noted to be low; therefore, the decision not to perform endocyclophotocoagulation was also made.

The traction suture was removed. TobraDex ophthalmic ointment was placed in the eye. A light patch and shield was placed. The patient was brought to the postanesthesia care unit in stable condition. The patient tolerated the procedure well There were no complications.

ICD-10-CM code(s) ____________________________________

11. Pre-op Diagnosis: Ptosis

Post-op Diagnosis: Ptosis

Procedure: Mullerectomy

Anesthesia: MAC

Complications: None

Indications: The patient had been complaining of a progressive drooping of the lid which was interfering with their ability to see to watch TV and read. By holding her lid up she can see better. Visual field testing was performed which demonstrated a loss of the superior visual field. By taping the lid up into its proper anatomic position there was a marked improvement m the field. Neosynephrine 10% instilled into the eye resulted in a good elevation of the lid.

Procedure Description: After informed consent was obtained, the patient was brought to the operating room. A supraorbital block of local anesthetic consisting of a 50/50 mixture of Xylocaine 1% with epinephrine mixed with Marcaine. 75% with epinephrine. The face was then prepped and draped in the usual sterile fashion. The lid was then everted over a Desmarres retractor. The superior border of the tarsus was then marked with a marking pen. Another line was then marked on the conjunctiva 8 mm superior to this. The conjunctiva and Mueller’s muscle were then freed up from the underlying levator muscle by pulling on these tissues with an Arson forceps. A Mullerectomy clamp was then placed on the two previously marked lines. The clamp was shut to enclose the 8 mm of Mueller’s muscle and conjunctiva. A 6-0 plain suture was then run along the underside of the clamp. The clamp and its tissues were then excised by running a #15 Barde Parker blade along the underside of the clamp. The 6-0 plain suture was then run once again along the length of the wound to close the edge of tarsus to the conjunctiva. The suture was buried temporally. The patient tolerated the procedure well and left the operating room in good condition.

ICD-10-CM code(s) _________________________________

12. Operative Report
Preoperative Diagnosis: Bladder calculus

Postoperative Diagnosis: Bladder calculus

Anesthesia: General endotracheal and caudal block

Findings: Single 1.5 cm bladder calculus removed in toto

Estimated Blood Loss: Negligible

Drains: 10 French Foley catheter per urethra

Indications: This is a 4-year-old male who recently presented with dysuria. He has undergone treatment for a presumed medial baffle. After a similar episode of dysuria yesterday he was seen at an outside facility where a CT scan was obtained that showed a bladder calculus. He presents for surgical management.

After informed consent was obtained the patient was brought to the operating suite and placed supine on the OR table. General endotracheal anesthesia was induced. The patient was administered IV Cefazolin. The lower abdomen and penoscrotal region were sterilely prepped and draped in the usual manner.

An expressed void showed no deflection of his urinary stream. A 10 French Foley catheter was inserted per urethra, and the bladder was filled with warm saline until it was palpable. A low transverse incision was made. This was carried through the subcutaneous tissue with electrocautery. The fascia was divided transversely yielding the underlying rectus muscle. The rectus muscles were separated in the midline yielding the bladder. Retraction sutures were placed on either side of the bladder, and the bladder was opened in the midline. After the bladder was evacuated, a ringed forceps was passed into the bladder, and the calculus was removed. It was sent for chemical analysis.

The bladder was then closed in three layers using 4-0 chromic suture in a running fashion. First the mucosa was closed. This was followed by a two layer muscle closure. The rectus muscles were reapproximated with interrupted 4-0 Vicryl suture. The fascial layers were reapproximated with 4-0 Vicryl in a running fashion. The subcutaneous tissues were reapproximated with 4-0 Vicryl in interrupted fashion, and the skin was closed with 4-0 Vicryl in a subcuticular fashion. Mastisol and Steri-strips were applied to the incision. The patient’s Foley catheter was connected to a drainage bag. He was then turned to the lateral position, and caudal block was performed by anesthesiology. He was returned to the supine position and awakened from general anesthesia. He was transferred to the post anesthetic care unit in stable condition.

ICD-10-CM code(s) ___________________________________

13. Subjective: This 17-year-old patient presents to the emergency department after racing motorcycles earlier today. He had his helmet on as well as all of his racing gear. He actively races motorcycles and has done this all summer long, winning a number of times. He came over a jump and lost control of the bike, going over the handlebars. He denies hitting his head but landed on his left elbow and his left knee and has had some discomfort in these areas since. He tells me that he was not going fast, then approximately 30 mph. He denies any loss of consciousness. The main complaints center only on the left knee and the left elbow.

Objective: The patient is in no acute distress, nontoxic appearing. During an expanded problemfocused examination, he is alert and oriented. Eyes: PERL, EOMI conjugate without nystagmus. Fundoscopic exam reveals the disks to be sharp and the TMs normal. Throat: clear with teeth intact. Neck: non tender. No palpable discomfort or adenopathy. He has intact clavicles. Lungs: clear. Heart: regular rate and rhythm. Abdomen: soft; no hepatosplenomegaly, rebound, or guarding. He has good upper- and lower-extremity strength. His right arm is non tender to palpation. The left arm has a small amount of tenderness around the elbow joint, but there is no obvious deformity and he does have good, active motion. He has no tenderness with movement of the hips and no tenderness down the long bones of the lower extremities. There is mild tenderness at the left knee. The knee is intact with negative drawer sign and minimal tenderness along the lateral collateral ligament region. There is no real tenderness along the joint line or over the mediocollateral ligament. Both of these ligaments are intact with stress. X-rays of the left knee and left elbow are negative for fracture. Assessment: Contusion, left elbow and left knee (the MDM was of low complexity).

Plan: Ice, Tylenol; recheck if not improving over the next few days, otherwise on a prn basis.

ICD-10-CM code(s) ________________________________

14. Preoperative Diagnosis: Lentigo maligna of the right neck

Postoperative Diagnosis: Same Procedure: Excision of 8 cm lesion, right neck, layered primary closure

Anesthesia: Local with IV sedation

Estimated Blood Loss: Minimal

Complications: None

Procedure: The patient was placed in the supine position. She was prepped and draped in the usual sterile fashion. Her previous biopsy indicated positive margins anteriorly and, therefore, the anterior extent of the lesion was drawn out. Beyond this marking, a 0.5 cm margin was drawn out. This was infiltrated with 1% Lidocaine with Epinephrine. A 15 blade scalpel was used for full excision of the lesion. The specimen was sent for permanent histopathologic examination.

Light undermining of all margins was performed. Primary closure was able to be obtained with layered closure using 3-0 and 4-0 Monocryl followed by 5-0 nylon.

The patient tolerated the procedure well, no complications were encountered. ICD-10-CM code(s) ____________________

15. Preoperative Diagnosis: Displaced right olecranon fracture

Postoperative Diagnosis: Displaced right olecranon fracture

Procedure: Open reduction and internal fixation of right olecranon fracture

Anesthesia: General

Tourniquet Time: Approximately 1 hour, 250 mm Hg

Estimated Blood Loss: Minimal Patient was identified, brought to the operating room, placed on the operating table in supine position where appropriate monitoring devices were attached and adequate general anesthesia was obtained. The right arm was prepped and draped in the usual fashion for right arm surgery. The right arm was elevated and exsanguinated with an Esmarch bandage. Tourniquet was inflated to 250 mm Hg and remained inflated for approximately 1 hour during this procedure. Attention was directed to the posterior aspect of the right elbow where a linear incision was made overlying the proximal ulna. Appropriate skin flaps were raised. There was noted to be a displaced fracture of the olecranon. The fracture fragments were curetted and irrigated. The fracture was then reduced with 2 parallel, 2 mm K-wires and the longitudinal axis of the ulna from proximal to distal direction, thereby reducing the fracture. The reduction was checked with intraoperative fluoroscopy. The reduction was further maintained by utilizing a standard technique cerclage wire. The wire was tightened and there was noted to be compression at the fracture site. After this was completed, the previously placed K-wires were bent and gently tapped further into the bone and cut and left subcutaneously. A cerclage wire was also cut and left subcutaneously. When this was completed, the elbow was put through a range of motion. The reduction was noted to be stable. The wound was irrigated with irrigation solution. Hemostasis was obtained utilizing electrocautery. The wound was closed utilizing a 4-0 Vicryl in a running subcuticular fashion. The wound was reinforced with skin staples. A bulky compressive dressing was applied to the arm, incorporating a long arm fiberglass splint and the patient was considered ready for discharge from the operating room.

ICD-10-CM code(s) _________________________________

16. S: This normally active, healthy 57-year-old female patient presents to the office today for evaluation of hip pain after falling at home out of her bed. She reports her R hip became immediately sore and painful with difficulty bearing weight on her R side. No other complaints or injuries reported. Patient took 3 Advil after fall this morning with limited relief.

O: Patient appears to be in mild distress. She ambulated to the exam room slowly favoring her R hip/leg. BP today is 145/82. HEENT within normal limits. Lungs clear. Abdomen soft, normal bowel sounds. Patient is not taking any medication. Musculoskeletal exam revealed R hip tender to touch with bruising. Walking is painful. Patient did drive herself to the office with some discomfort. X-rays taken in office today ruled out fracture.

A: Contusion to R hip

P: Patient to limit physical activity for 2 weeks, apply alternative heat/cold next 72 hours and continue with over the counter as directed by manufacturer. Patient instructed to call office if pain worsens. Patient declines pain medication at this time. Anticipate full recovery. No fractures noted on X-ray.

ICD-10-CM code(s) __________________________________

17. Indication: Left vocal cord paralysis

CT Neck with Contrast: Axial CT cuts were obtained from the top of the orbits down to the thoracic inlet using 100 cc of Isovue 300. 13 mm axial CT cuts were also obtained through the larynx. Sagittal and coronal computer reconstruction images were also obtained.

Indications for Nonionic Contrast: None

No mass lesion within the posterior nasopharynx or oropharynx. There are multifocal punctate calcifications in the right palatine tonsil. The submandibular and parotid glands are unremarkable. There are subcentimeter anterior cervical and left submandibular lymph nodes. There are subcentimeter left internal jugular lymph nodes. The left pyriform sinus is slightly larger than the right and there is dilatation of the left laryngeal ventricle. There is probably atrophy of the left true vocal cord best seen on the 13 mm thick images. The left arytenoid cartilage has a more medial position than the right. The thyroid glands are unremarkable. The visualized upper mediastinum is unremarkable. Please refer to the CT of the chest report.

Impression
1. Findings compatible with left vocal cord paralysis
2. No cervical mass or adenopathy

ICD-10-CM code(s) ________________________________

18. Subjective:
CC: Patient presents with diabetes

HPI: Type 2 diabetes using oral medications and diet that was diagnosed years ago. Patient feeling well and taking medication as prescribed, see flow sheet. Patient tries to follow diet and exercises sporadically, takes an ARB inhibitor. Patient uses OneTouch Ultra and keeps a log book. Glucose readings are in the range of 110-135. No hypoglycemic episodes. Patient checks feet daily and sees eye doctor regularly.

ROS:
All systems negative per review of flow sheet signed and dated today. Current Meds: Cozaar 50 mg 1 by mouth every day, Zaroxolyn 5 mg 1 qd 1 by mouth every day, Glucophage 1000 mg take one tablet by mouth two times a day.

Objective:
BP: 140/58 Pulse: 72 T: 96.7 Ht: 5’1” Wt 279 lb BMI: 51.5
ENMT: auditory canals normal. Tympanic membranes are intact. Oral mucosa: pink, smooth and moist. Posterior pharynx shows no exudate, irritation or redness
CV: rate is regular. Rhythm is regular. No heart murmur appreciated
Extremities: no clubbing, cyanosis or edema. Digits or Nails: Toes are normal, amputation of the left great toe. No chronic paronychia of the toenails bilaterally
Skin: Skin is warm and dry

Assessment:
Diabetes mellitus without complications; will check Hg A1c in 6 month, good range of 5.7; refills on med
Hypertension benign; higher BP today, will add second 40 mg of Lasix in pm, bring BP record on next visit
Goal for blood pressure is less than 130/80. F/U in three months, after labs.

ICD-10-CM code(s) ___________________________________

19. Subjective: This is a return visit to clinic for a 50-year-old man who I have followed for a long time with class B3 HIV infection and AIDS that is multidrug resistant. He has a long history of poor adherence with medications.

Past Medical History:
AIDS
Gastroenteritis
MAC in stool
Nausea
Anemia
Renal insufficiency
Medications:
Epzicom 1 a day
Raltegravir 400 twice a day
Reyataz 400 once a day
Ambien 10 at night

His caseworker continues to see him each week and work on adherence. He continues to miss doses regularly. Currently, his most common missed dose is Raltegravir.

Social History: He remains abstinent from alcohol. He is down to five cigarettes a day. He has moved into a bigger apartment with his partner. Unfortunately, his wife has cancer and is on chemotherapy. His partner is HIV positive.

ROS:

He is doing well. His weight is stable. Nausea is manageable. He does not have any abdominal pain. His back is sore from moving.

Objective: On physical exam, he is a well-appearing man in no acute distress. He is in good spirits today. His weight is 47.4 kilos. Blood pressure 100/82, temperature 97.7. He has no teeth. Chest is clear. Skin is dry.

Impression: A 50-year-old man with AIDS and a long history of sporadic and incomplete medication adherence. His labs are relatively stable. He does have a macrocytic anemia.

Plan:
Continue Epzicom, Raltegravir, and Reyataz and continue to try to optimize adherence. Return to clinic in 3 months. Needs a follow up hepatitis A vaccine, which is given today.

ICD-10-CM code(s) ___________________________________

20. Preoperative Diagnoses:
1. Right open index distal phalanx fracture
2. Bony mallet

Postoperative Diagnoses:
1. Right open index distal phalanx fracture
2. Bony mallet

Procedures Performed:
1. Irrigation and debridement of an open fracture, right index finger for bony mallets down to bone.
2. Open treatment and internal fixation, right index finger, distal phalangeal index bony mallet, open.
3. Fluoroscopy, three plus views, right hand and wrist.
4. Application of short-arm splint, right upper extremity, Gauntlet.

Disposition: Recovery at home.

Indications for Procedure:
The patient is a young lady that sustained an open fracture at the distal phalanx and developed a bony mallet finger to the right index distal phalanx. It was determined she would need irrigation and debridement of the open fracture in the distal phalanx in the right index finger. It was also determined that she would need open treatment and internal fixation of the right distal phalangeal index bony mallet finger. The patient understood this and wished to proceed with the operation. She understood the potential risks of the surgery including but not limited to DVT, PE, infection, bleeding, anesthetic complications, or possibly even death.

Description of Procedure:
The patient’s appropriate extremity was identified as the right index finger. It was marked prior to the operative procedure and confirmed as permanent. The patient was taken to the operative suite and placed in the supine position with the hand table in place. At this point, an incision was made over the area of the open wound in the dorsal aspect of the distal phalanx just proximal to the distal phalangeal joint. We thoroughly irrigated and debrided the wound itself in the area of the bony mallet in the open fracture site, and we thoroughly irrigated. We used normal saline into the joint space as well. It was noted that extensor tendon was completely disrupted as well as small fleck of bone in the open fracture itself. At this point, we determined that we would perform an open treatment and internal fixation with the use of a 0.062 K-wire into the distal phalanx and into the middle phalanx itself to keep the finger of the index into a straight position but not a chronic mallet flexed distal phalanx deformity. Fluoroscopy was done on the hand and wrist on the right side throughout the procedure in addition postoperatively to confirm appropriate placement the pin and the alignment of the digit. The patient was transported to the recovery in stable condition with a splint in place as a shortarm right Gauntlet splint. The block was performed on the right upper extremity for postoperative pain separate from the general anesthetic procedure itself and done by general anesthesia services for postoperative pain.

ICD-10-CM code(s) ___________________________________

21. S: The patient is here because she feels like her uterine fibroids are giving her problems. She has not had periods for several years. She is due for a physical in the not too distant future. She has not had any vaginal bleeding, no trouble urinating or moving her bowels. No blood in her stool or urine. No nausea or vomiting.
O: Blood pressure is 120/70. No exam was done, discussion only.
A: Uterine fibroids
P: 1. Ultrasound of the pelvis
2. Appointment with Dr. xxxx or Dr. xxxx for consultation regarding fibroids.
3. Follow up with us for a physical at her convenience. 4. Return check otherwise p.r.n.

ICD-10-CM code(s) __________________________________

22. S: Here to follow up on her atrial fibrillation. No new problems. Feeling well. Medications are per medication sheet. These were reconstituted with the medications that she was discharged home on.
0: Blood pressure is 110/64. Pulse is regular at 72. Neck is supple. Chest is clear. Cardiac normal sinus rhythm.
A: Chronic atrial fibrillation, currently stable.
P: 1. Prothrombin time. 2. Follow up with myself in 1 month, sooner as needed if has any other problems in the meantime. Will also check a creatinine and potassium today as well.

ICD-10-CM code(s) _________________________________

23. Chief Complaint: “I got a lot of stress and I have suicidal thoughts.”
History of Present Illness: Male patient had been seeing his primary care physician for anxiety and depression since 2001. This began with job related stress; he was a supervisor and was on 24-hour call. The patient became increasingly depressed and began isolating himself and staying in bed on his day off. The patient has depressive symptoms of crying, insomnia, anorexia with recent 20-pound weight loss, decreased concentration, psychomotor retardation, and suicidal ideation
with plan. In addition, the patient has auditory hallucinations and hears vague voices talking to him. He will sometimes hear his wife call him when she is not present. At the present time, the patient has been taking Wellbutrin 150 milligrams daily, Lexapro 20 milligrams daily, and Xanax 1 milligram three times a day. He also uses a Combivent inhaler. He has been to the emergency room on several occasions for panic and anxiety attacks and he was treated symptomatically and
released. Past Psychiatric History: See above. There is no evidence of physical, emotional, or sexual abuse as a child and there is no evidence of substance abuse. He denies any family history of emotional illness.
Medical and Surgical History: At work, the patient was moving a chlorine tank, which ruptured, and he inhaled chlorine gas and was hospitalized for a week. He also has asthma and sinus problems.
Social History: The patient has a high school education. He worked for 38 years before he was disabled. He feels that he gets along well with people. His marriage is solid but his wife’s mental problems, which have been going on for five or seven years, cause him stress.
Review of Systems:
HEENT - Non-contributory.
Cardiorespiratory - Patient has shortness of breath.
Gastrointestinal - Non-contributory.
Genitourinary - Non-contributory.
Musculoskeletal - Non-contributory.
Mental Status Exam: Patient is a well-nourished, well-developed white man in moderate to marked distress. He is tearful during the initial interview. His mood is depressed and his affect is appropriate for the situation. Stream of mental activity is unremarkable; there is no evidence of delusions or ideas of reference. He does have auditory hallucinations. He appears to be of average intellectual functioning. His memory is good for remote and recent events. His general knowledge is good.
Insight and judgment are fair.

 

Inventory of Strengths and Weaknesses: Patient's primary strength is his recognition of illness and willingness to accept help. Weaknesses include difficulty in dealing with stressful situations and difficulty in controlling impulses at times.
,br> Diagnosis: Axis I
1. Major depressive illness, recurrent, with suicidal ideation and plan and psychotic features.
2. Panic/Anxiety disorder without agoraphobia.

Treatment Plan: Patient will have individual and group therapy. His Wellbutrin will be increased and he will be started on low doses of Seroquel, which will be increased if psychotic symptoms are not abated.

Problem Summaries and Recommendations: This 58-year-old married white male is admitted for treatment of depression with suicidal ideation and psychotic features secondary to multiple stressors as noted in history and physical.

Prognosis: Fair to good.

Estimated Length of Stay: 7 to 10 days.

Discharge Criteria: Resolution of depression, suicidal ideation and auditory hallucinations. Follow-up treatment plan in place.

ICD-10-CM Code(s): ___________________________

24. The patient is a 48-year old female who presents with a partial-thickness burn of her left hand due to a motorcycle accident. She is right-handed. She can move the fingers. Complete review of systems is negative. She has had no prior history of major illness or hospitalization, except for vaginal birth of her 15-year-old daughter.

Examination: The left hand shows that the palm and extensor surface of the hand are normal. The affected areas are the fingers. The thumb is somewhat spared, but the four fingers of the hand, especially the left middle finger and the left index finger, have involvement with the burn. None of the burned fingers have a complete, circumferential burn. The patient has full range of motion of the fingers of the hand and can bend, flex and extend the fingers. Sensory is intact. Motor is intact. Pain on touch and movement. The burn area is mostly reddened and painful to the touch. There are several small blisters. The body surface area involved is less than 5 percent.

Today we debrided the partial-thickness burn with a #15 blade, normal saline cleanse and we applied Silvadene and a dry sterile dressing to the fingers of the left hand. The patient will continue applying Silvadene twice daily. We will follow-up with her in 4 days.

ICD-10-CM Codes ___________________________________

25. Preprocedure Diagnosis: Basal cell carcinoma of the right neck, left lateral brow, right chest, and skin lesion of the back

Postoperative Diagnoses: Basal cell carcinoma of the right neck, left lateral brow, right chest, and skin lesion of the back

Procedure:
1. Wide-local excision of left lateral brow lesions, approximately 3 cm in size with intermitted closure
2. Wide-local excision of the right neck lesion with intermediate closure
3. Wide-local excision of chest lesion with intermediate closure
4. Biopsy of back lesion

Anesthesia: Local

Procedure Note: The patient’s sites of intended excision were marked out in an elliptical fashion with a cuff of normal tissue surrounding each lesion. The sites were then prepped with Betadine and then injected with 1% lidocaine with 1/100,000 epinephrine. Starting with the chest the site was prepped with Betadine. A 15-blade scalpel was used to make an incision at previously marked site. The incision was carried down to the subcuticular fat. The lesion was then sharply dissected off the underlying tissue using a 15-blade scalpel. The lesion was tagged for pathologic orientation and handed off the field. Hyfrecator was used for hemostasis. The wound edges were sharply underlined using an Iris scissors. The wound was then closed using 3-O Vicryl for the deep layer followed by 4-O Prolene for the skin. A similar procedure was then carried on the right neck and left lateral brow area. On the left lateral brow 5-O Prolene was used for the skin. Once all these sites were closed attention was turned to the back. It was again prepped with Betadine and then injected with 1% lidocaine with 1/100,000 epinephrine taking care to aspirate prior to injection. It was once again prepped. A 15-blade scalpel was used to obtain a shave biopsy. Hyfrecator was used for hemostasis. The patient tolerated the procedure well.

Assessment and Plan: The patient was given instructions in cleaning of the incision sites. He should follow up in three days time for suture removal of the left lateral brow and seven to 10 days time for removal of chest and back sutures.

ICD-10-CM code(s) _________________________________

26. Chief Complaint: Reaccumulation of hematoma.

History Of Present Illness: The patient is a 15-year-old male who was seen by me last week for hematoma of the pinna that he suffered in wrestling practice. The patient underwent incision and drainage. He then had a bolster placed. He had his bolster removed on Friday. Some more hematoma was drained. The patient reports that he did well all weekend; however, he reinjured his ear yesterday in wrestling. The trainer put some Dermabond on the site. The patient presents today for re-drainage.

Review of Systems: The 10-system review of systems is negative.

Past Medical History: Negative.

Past Surgical History: Incision and drainage of right hematoma. Current Medications: None.

ALLERGIES: The patient has no known allergies.

Family History: Notable for grandfather with heart disease, grandmother with heart disease, grandmother with cancer, mother with kidney problems, uncle with diabetes, mother with headaches.

Social History: The patient lives with his mother, stepfather, and a sibling. He attends high school.

Physical Examination: Blood pressure is 122/72. Pulse is 67. Weight is 147 pounds. The patient is a well-developed, well-nourished male in no acute distress.

HEENT: Examination of the right ear demonstrated hematoma of the pinna. He has Dermabond on the previous incision and drainage site.

Assessment and Plan: The patient has recurrence of the hematoma. Unfortunately the Dermabond has sealed the hematoma in. I would recommend that we repeat the incision and drainage. With that in mind the following procedure was done.

Procedure: Incision and drainage of right pinna hematoma.

Anesthesia: Local.

Procedure Note: The patient’s ear was examined. It was injected with 1% lidocaine with 1/100,000 epinephrine taking care to aspirate prior to injection. It was prepped and draped in the usual fashion, A 15-blade scalpel was used to make and incision at the previous incision and drainage site. Curved Iris scissors were used to dissect in the wound with release of fresh hematoma. A bolster was then placed using Xeroform bolster was then sewn into place with 2-0 silk sutures. I would recommend that we keep the bolster in place for three days and I would like the patient to follow-up with me in three days time for removal of the bolster.

ICD-10-CM code(s) __________________________________

27. Note #2
Nurse Note: A six-year-old female presents with grandparents with a complaint of insect bite near her right eye. She states that she had an ant on her cheek yesterday. She states that she does not know if it bit her but does not know of any other bite. She states that it is now swollen and making her eye difficult to open.

Chief Complaint: Insect Bite

HPI: While out on a trail yesterday the patient sustained a bite under the right eye. This morning it is red and swollen. There is no drainage from the eye. It is itchy more than painful.

ROS: Const: denies fever, fussiness and loss of appetite. Eyes: Denies discharge but there is a red area under the eye. ENMT: Ears: denies hearing difficulty and ear pain. Nose and Sinuses: denies congestion. Denies nasal discharge. Denies mouth breathing. Resp: Denies Asthma, acute cough and wheezing. GI: Denies abdominal pain, constipation, diarrhea, nausea and vomiting. GU: Urinary: denies change in urine color, change in urine odor, dysuria, frequency and urgency. Skin: Denies symptoms other than stated above. Allergy/Immuno: Denies environmental allergies and seasonal allergies.

Current Meds: Polyviflor 0.5 mg chew

Allergies: NKDA

Past Medical History: Shot record: Varicella 07/11/08, Poliovirus 03/08/07, MMR 03/09/07 and DTaP 03/09/07. Physical exam: 07/11/08. Dental exam: 2008. Eye exam: Screening at school. Lead level 12/03/02 Normal. Pt has had the chickenpox vaccine. There are no medical problems. Pt has had no surgeries. The pt has no advanced directive.

Family History: Alcoholism, Drug Addiction and Hepatitis. Father: Hepatitis. Mother: Unremarkable.

Social History: Exposed to second hand smoke. Always uses a booster seat. There are smoke alarms in the house and a fire plan in place. The child lives with the father and paternal grandparents. Mother and father are both very involved and father has custody and mother has visitation rights.

Objective: BP: 88/62, Pulse: 84, Resp: 24, Ht: 48.5”, Ht%: 68th, Wt: 51 lbs and BMI: 15.2.

Exam: Const: Appears healthy. No signs of apparent distress present. Eyes: Conjunctivae clear, the globe does not appear involved, nor does the upper eyelid. The area under the eye is erythematous and edematous; she is able to open the eye easily. Vision intact and is 20/20 without corrective lenses. ENMT: Auditory canals are patent. Tympanic membranes have normal landmarks, no fluid or erythema bilaterally. Nasal mucosa shows congestion, moistness, normal color, discharge and clear discharge. Oral mucosa: pink, smooth and moist. Tongue appears pink and moist with no abnormalities. Posterior pharynx shows no injection, irritation or post-nasal drip. Tonsils appear normal. Neck: Symmetric and supple. Palpation reveals no swelling or tenderness. Resp: Chest expansion is adequate bilaterally. Respiration rate is normal. No wheezing. Lungs are clear bilaterally. CV: Rate is regular. No heart murmur appreciated. Lymph: No visible or palpable lymphadenopathy in the neck. Skin: Warm and dry with no rash or tenting.

Assessment and Plan: Cellulitis and Abscess of face. Ice the area when possible, questionable infection vs. reactive, but given the area involved, will cover with antibiotic. Grandmother cautioned about signs and symptoms of worsening infection and when to contact us. Rx given for Keflex 250 mg 1 po q 6 hr.

ICD-10-CM code(s) _________________________________

28. Nurse Note: The patient is a 9-year-old female who presents with her mother with a complaint of cold symptoms. States that she had a fever last week. Now she has stomach ache, sore throat and difficulty swallowing solid foods. States also has headache and stuffy nose.

Chief Complaint: As above.

HPI: Congestion, fever, nasal discharge and sore throat. Denies cough. Fever: Temperature reported to be 101.8 on Sunday, per mom. Sore throat: Described as scratchy. Exposed to cigarette smoke. Reports associated loss of appetite, diarrhea and nausea but declines associated vomiting and pain in mid abdomen.

ROS: Const: Denies chills and fever. ENMT: Ears: Reports congestion/fullness in the ears, but denies ear pain. Nose and Sinuses: Reports congestion. Reports nasal discharge. Resp: Reports cough, but denies asthma and wheezing. Skin: Denies rashes. Allergy/Immuno: Denies environmental allergies and seasonal allergies.

Current Meds: none

Allergies: NKDA

Past Medical History: Physical exam- Fall 2007, migraines.

Family History: Diabetes Mellitus II, Congestive Heart Failure, Hypercholesterolemia, Hypertension, Breast Cancer and Alzheimer’s disease. Father: unremarkable- on disability due to arm injury. Mother: unremarkable.

Social History: The child lives 50/50 share with the mother and father. The patient also has a brother and sister. The mother and father are both very involved. The home is not smoke free. Smokers are at mother’s home only. The family has a cat and a dog.

Objective: BP: 108/72, Pulse: 72, Temp: 98.4, Resp: 18, Ht: 55.75”, Wt: 86 lbs. BMI: 19.5.

Exam: Const: Ill appearing child and mildly dehydrated. ENMT: Auditory canals are patent. Tympanic membranes have normal landmarks, no fluid or erythema bilaterally. Nasal mucosa shows congestion, moistness and normal color, but no clear discharge. Oral mucosa: pink, smooth and moist. Tongue appears pink and moist with no abnormalities. Posterior pharynx shows injection and irritation, but no exudates. Tonsils appear normal. Neck: Symmetric and supple. Palpation reveals no swelling or tenderness. Resp: Chest expansion is adequate bilaterally. Respiration rate is normal. No wheezing. Lungs are clear bilaterally. CV: Rate is regular. Rhythm is regular. No heart murmur appreciated. Lymph: No visible or palpable lymphadenopathy in the neck. Skin: Warm and dry with no rash.

Assessment and Plan: Pharyngitis, Acute. Push fluids and rest. Rx is given for Amoxicillin 400 mg 1 po tid x 10 days. Nausea. Follow up if symptoms persist.

ICD-10-CM code(s) __________________________________

29. Nurse Note: 19-month-old female presents with mom for follow up for results of recent blood work. Mom concerned about child scratching herself when scolded.

Chief Complaint: Patient is here with mom to review lab work from last visit, pica. Per mom eating whatever she got her hands on. Started to give MVI. Seems to have less pica.

HPI: From the last note she was eating non-food items. Present for 3 weeks. Has improved since last visit. Mom states that when she is corrected she hits herself or hits head on the floor. Then dad yells at her.

ROS: Const: Denies fever, fussiness and loss of appetite, picky eating. ENMT: Ears: Denies hearing difficulty and ear pain. Nose and Sinuses: Denies congestion. Denies nasal discharge. Denies mouth breathing. Resp: Denies asthma, acute cough and wheezing. GI: Denies abdominal pain, constipation, diarrhea, nausea and vomiting. GU: Urinary: denies change in urine color, change in urine odor, dysuria, frequency and urgency. Skin: She has scratch marks on her belly, done today.

Current Meds:

Allergies: NKDA

Past Medical History: Physical exam 5-5-08. The patient was born full term, SVD, no complications, no jaundice. Birth weight 6lbs, 6oz. Birth length 19”. Vaccinated for chickenpox. No medical problems, surgeries or assistive devices.

Objective: Pulse: 124, Temp: 97.6, Ht: 32.25”, Wt 23lb. HdCir: 17.25.

Exam: Const: Healthy appearing toddler. No signs of apparent distress. Eyes: conjunctivae clear. ENMT: Nasal mucosa shows congestion, moistness, normal color, discharge and clear discharge. Oral mucosa: pink, smooth and moist. Tongue appears pink and moist with no abnormalities. Posterior pharynx shows no injection, irritation or post-nasal drip. Tonsils appear normal. Neck: Symmetric and supple. Palpation reveals no swelling or tenderness. Resp: Chest expansion is adequate bilaterally. Respiration rate is normal. No wheezing. Lungs are clear bilaterally. CV: Rate is regular. Rhythm is regular. No heart murmur appreciated. GI: Abdomen is nondistended, nontender and soft. Bowel sounds normoactive. Palpation of the abdomen reveals no tenderness. No palpable hepatosplenomegaly. Lymph: No visible or palpable lymphadenopathy in the neck. Skin: Warm and dry, scratches on abdomen.

Assessment and Plan: Pica. Reviewed labs. Continue to give MVI. Follow up for 2 year visit and prn. Discussed discipline, use distraction and time out no more than 1 min per age.

ICD-10-CM code(s) _________________________________

30. Chief Complaint: Patient presents for a scheduled school age well child visit. The patient is an 11-year-old male. Patient is accompanied today by her father. Parents have no specific concerns.

Diet: Adequate amount of calcium intake. The child drinks 46 ounces of water per day. The source is city water. Currently eating age appropriate foods daily. Diet is appropriate for age. No eating disorders. Sleep: Sleep patterns are normal. No sleep disturbances experienced. Hearing screen: Able to hear 500 Hz, 2000 Hz and 4000 Hz at 25 dB HL in both ears. Behavior: Described as very good most of the time. Patient has no behavior problems. Has never been sexually active. Using age appropriate discipline and withdrawal of privileges as a form of discipline. Child does get along with parents and siblings and does chores. Patient is in the sixth grade. School performance is average. The patient is active. Anticipatory Guidance: No drugs or alcohol in the home. Standard anticipatory guidance and safety sheet given.

HPI: Presents for physical exam. Patient is feeling well. Immunizations will have to wait until shot record comes in.

ROS: The patient denies constitutional symptoms, respiratory symptoms, gastrointestinal symptoms, male genital problems, and skin, hair and nail symptoms.

Current Meds: none

Allergies: NKDA

Past Medical History: Physical and dental exam in 2008. Eye exam in 2007.

Family History: Unremarkable

Social History: The home is smoke free. There is no history of abuse.

Objective: BP: 98/78, Pulse: 72, Temp: 97.8, Ht: 59”, Wt: 117 lbs, BMI: 23.6.

Exam: Const: Healthy appearing child, well nourished and alert. Weight within the normal range for stated age. Communicates normally. Eyes: 20/20 in both eyes without correction. No discharge from the eyes. PERRL. Normal eye movement. ENMT: Auditory canals are patent. Tympanic membranes have normal landmarks, no fluid or erythema bilaterally. Nasal mucosa shows moistness and normal color, but no discharge. Oral mucosa: pink, smooth and moist. Neck: supple, with no adenopathy. Resp: Respiration rate is normal. Lungs are clear bilaterally. CV: Rate is regular. Rhythm is regular. Pedal pulses: 2+ and equal bilaterally. GI: Abdomen is nondistended, nontender and soft. Bowel sounds normoactive. No palpable hepatosplenomegaly. GU: Normal genitalia. No hernias. Musculo: Spine: No scoliosis. Upper extremities: Strength: Normal and symmetric. ROM is physiologic. Lower extremities: normal and symmetric. ROM is physiologic. Skin: No rash or lesions. Neuro: Mood is normal. Affect is normal.

Assessment and plan: Normal physical exam. Follow up prn.

ICD-10-CM code(s) ___________________________________

31. Nurse Note: 15-year-old female presents with lump on left breast. Pt states she first noticed 2 weeks ago. Not painful.

Chief Complaint: Patient present with a breast lump.

HPI: Patient feeling well. No pain with the lump. Noticed 2 weeks ago. Affects outer left quadrant of the left breast at the 3 o’clock position. Rated as mild. Has shown no change since onset. Reports associated family history of breast cancer, but denies associated nipple discharge, rash, skin changes and skin irritation. Mom had breast cancer in 2000 at age 44. She has not had a reoccurrence of breast cancer. MGM also has breast cancer.

ROS: Const: Denies chills, fatigue, fever and weight change. General health stated as good. CV: Denies chest pain and palpitations. Resp: Denies cough, dyspnea and wheezing. GI: Denies constipation, diarrhea, dyspepsia, dysphagia, hematochezia, melena, nausea and vomiting. GU: Genital: denies dysmenorrheal, irregular menstrual periods and breast tenderness. Urinary: denies dysuria, frequency, hematuria, incontinence, nocturia and urgency. Musculo: Denies arthralgias and myalgia. Skin: Denies rashes. Neuro: Denies dizziness and lightheadedness.

Current Meds: none

Allergies: NKDA

Past Medical History: Eye exam in 2006. No medical problems. Pt had eye surgery for lazy eye at 18 mos of age.

Family History: Diabetes Mellitus II, Hypertension, Breast Cancer, and Heart Disease.

Social History: Former cigarette smoke – quit beginning 10-07. The child lives with the mother and two sisters. The home is smoke free.

Objective: BP: 118/80, Pulse: 72, Temp: 97.1, Resp: 16, Ht: 68”, Wt: 128 lbs, BMI: 19.5.

Exam: Const: Appears well and comfortable. No signs of apparent distress present. Resp: Respiration rate is normal. No wheezing. Ausculate good airflow. Lungs are clear bilaterally. CV: Rate is regular. Rhythm is regular. No heart murmur appreciated. Extremities: No clubbing, cyanosis or edema. Breasts: Breast exam was performed while patient was in a supine position. Exam was done with a chaperone present, mother in room. Breasts normal on inspection. There are no skin changes. Left cyst, located at 2 o’clock position and left breast is nontender. Right breast is normal. Cyst are round in the skin and not the breast tissue. Was able to pick it up and move it around. Pea size. Nipples: No discharge of the nipples bilaterally. Axillae: Axillae normal. Musculo: Walks with a normal gait. Skin: Skin in warm and dry.

Assessment and Plan: Left breast lump. I will get an ultrasound of the left breast. I instructed the patient to follow up after the test and also if the symptoms get worse or changes. I will give her Gardasil #2 shot today.

ICD-10-CM code(s) _____________________________________

32. Note #1
Diagnosis: Lung cancer

Operation: Flexible bronchoscopy, mediastinoscopy with biopsies, right thoracotomy with right middle and lower lobectomy.

Indication: This 57-year-old former smoker presents with a 4 cm right lower lobe mass peripherally which is biopsy proven adenocarcinoma. PET CT does not suggest any regional or distant metastatic disease.

Technique: After induction of satisfactory general anesthesia, flexible fiberoptic bronchoscopy was performed. Airways were essentially normal with minimal secretions. No endobronchial lesions. The patient was kept supine and neck was prepared with DuraPrep and draped in the sterile fashion. A transverse incision was used and deepened with cautery. The pretracheal fascial plane was entered and the mediastinoscope easily passed. Samples of nodes from 3 different stations were taken from the subcarinal area, the right tracheobronchial angle area, and the low pretracheal area. All were negative for neoplasm. The wound was irrigated, checked for hemostasis, and closed with absorbable sutures and a dry sterile dressing was placed. A double-lumen lube was placed and its proper position confirmed bronchoscopically. The patient was then placed in the left lateral decubitus position, again padded appropriately, prepared, and draped. A lateral thoracotomy approach was used, and the chest entered in the sixth intercostals space. A small portion of #6 rib was taken posteriorly to aid with exposure. A pleural space was freed with no adhesions to the chest wall. There was a mass with puckering of the visceral pleura posteriorly in the lower lobe. We began by dissecting in the fissure and found some very large abnormal-appearing nodes between the middle and lower lobes stuck to the pulmonary artery with branches of the pulmonary artery to the middle lobe direct over this in a very dangerous way. It was obvious that taking the middle lobe was the right approach. She gets more clearance from these abnormal-appearing nodes and to avoid dangerous dissection along the pulmonary artery. The fissure between the lower and upper lobes was completed posteriorly with sharp dissection and between the upper and middle lobes medially with a stapler with reinforcements. This allowed exposure of the pulmonary artery. The inferior pulmonary ligament was taken down with cautery and the inferior pulmonary vein was taken with a vascular stapler. I dissected out a branch of the upper pulmonary vein, which drained the middle lobe and divided this with a stapler as well. This opened up the fissure quite a bit more and allowed us to identify the branches of the pulmonary artery to the middle and lower lobes and these were divided with vascular stapler as well. Lymphatic tissue was dissected up along with the specimen. We found some low subcarinal nodes, which could not be reached with the mediastinoscope and these were taken and submitted separately as well. The bronchus was dissected out. The stapler was applied across the intermediate bronchus and we had good ventilation to the upper lobe. The stapler was then applied and the specimen was removed from the wound comprising the middle and lower lobes. The chest was then irrigated with warm saline. We checked carefully for hemostasis and the staple lines at the bronchus were checked to a pressure of 25 mm Hg with no air leak seen. Two chest tubes were then brought through separate stab wounds and secured. The right upper lobe was ventilated normally and then the closure was carried out with #1 PDS to the pericostals. Running absorbable sutures were used for the muscle, subcutaneous, and skin. Dry sterile dressings were placed. The blood loss was minimal and no transfusion was required. The patient was extubated and taken to recovery in stable condition.

ICD-10-CM code(s) ___________________________________

33. Preoperative Diagnosis: Symptomatic, recurrent, left carotid stenosis.

Postoperative Diagnoses: Symptomatic, recurrent, left carotid stenosis, intimal hyperplasia.

Operative Procedure: Re-do left carotid endarterectomy with extensive Dacron patch angioplasty.

Indications for Procedure: The patient is a 59-year-old white male who underwent carotid endarterectomy for symptomatic left carotid stenosis on 08/15/05. He was due for his yearly carotid ultrasound, again having recurrent left eye visual changes and left facial numbness. He saw Dr. Smith, and carotid ultrasound was done that was indicative of recurrent disease on the right side. He was admitted on 08/17/06, and carotid CT angiogram was done. This demonstrated recurrent 90% left internal carotid artery stenosis extending into the common carotid artery. The patient has been neurologically stable. He is taken to the operating room for re-do left carotid endarterectomy.

Operative Findings: There was extensive layering of intimal hyperplasia with no evidence of recurrent atherosclerosis.

Procedure: After the induction of satisfactory general endotracheal anesthesia and placement of monitoring lines including a right internal jugular central line due to the patient’s limited peripheral IV access, the left neck was prepped and draped in a sterile fashion. The previous incision was carefully reopened. Using sharp dissection, the common carotid artery and its branches were dissected free. The patient was systematically heparinized and after a few minutes clamps applied to the common carotid artery and its branches. A longitudinal arteriotomy was carried out with findings as above. A silastic balloon-tip shunt was inserted first proximally and then distally, with restoration of flow. Endarterectomy in the standard fashion was not possible due to layering and intimal hyperplasia. Several layers of intima were removed and the endarterectomized surfaces irrigated with heparinized saline. An oval Dacron patch was then sewn into place with running 6-0 Prolene. Prior to completion of closure of the shunt, air and debris were evacuated. After closure, there were excellent pulses throughout the carotid system.

ICD-10-CM code(s) _________________________________

34. Preoperative Diagnosis: Adenocarcinoma of the esophagus. History of Barrett’s esophageal epithelium.

Postoperative Diagnosis: Adenocarcinoma of the esophagus. History of Barrett’s esophageal epithelium.

Operative Procedure:
1. Ivor-Lewis esophagogastrectomy with intrathoracic reconstruction
2. Feeding jejunostomy
3. Pyloroplasty
4. Partial resection of right sixth rib

Cosurgeons: Dr. Smith

Indications for Procedure: Patient is a 64-year-old white female with a long-standing history of Barrett’s esophagus. She underwent periodic endoscopy. She was recently found to have an invasive adenocarcinoma without evidence of metastatic spread on work-up. She was referred for resection.

Operative Findings: There was tumor present at approximately 30 cm in the junction of the mid to distal esophagus. The GE junction was clear. Margins proximal and distal to the resection were negative. The proximal margin also showed only squamous epithelium and no evidence of Barrett’s epithelium. No evidence of intrathoracic or intraabdominal tumor spread.

Operative Procedure: After the induction of satisfactory double-lumen endotracheal anesthesia and placement of monitor lines, the patient was placed supine on the operating table and the abdomen was prepped and draped in sterile fashion. Midline abdominal incision was made and the stomach mobilized by Dr. Smith with a series of ligatures along the greater curvature and lesser curvature. After mobilization of the stomach was satisfactory and hemostasis was obtained a Heineke-Mikulicz pyloroplasty was performed with 4-0 Monocryl suture, opening the pylorus longitudinally and sewing it transversely. A 16 French red rubber catheter was then used as a feeding jejunostomy, placed in Witzel maneuver used to cover the track with 4-0 Monocryl. This was brought out through the abdominal wall and sutured into place. Wound was then irrigated with copious amounts of antibiotic saline and closed with running looped PDS suture. Vicryl and skin staples sterile dressing was applied.

ICD-10-CM code(s) __________________________________

35. Procedures Performed:
1. Left and right heart catheterization (for congenital anomaly)
2. Left ventriculography and coronary angiography
3. Intracardiac echocardiography

Indication: Secundum-type atrioseptal defect. Congestive heart failure, chronic, systolic.

Brief History of Present Illness: This is a 63-year-old patient who has chronic dyspnea on exertion consistent with CHF NYHA class III. Outpatient evaluation revealed pulmonary hypertension and a dilated pulmonary artery, following which subsequent noninvasive testing included an echocardiogram as well as coronary CT angiography. This revealed a large Secundum-type atrial septal defect. He has been managed with medical therapy and presents today for potential closure of this defect with a percutaneous septal occluder device. Risks/benefits ratio of procedure was explained, and informed consent was obtained.

Procedure: On arrival to the lab, the patient was in stable condition. Initially, a 5-French sheath was placed in the right common femoral vein, an 11-French sheath was placed in the left common femoral vein, a 5-French sheath was placed in the left common femoral artery. Hemodynamics were measured using sheath sidearms as well as using a 7-French pulmonary artery Swan-Ganz catheter (after upgrading sheaths to 11-French at a later point in time). Intracardiac echocardiography was performed using an AcuNav 10-Prench intracardiac echocardiography catheter with standard technique.

Complications: None immediate.

Hemodynamic Findings:
1. AC 120/78 (94 mm Hg mean)
2. LV 120/17 mm Hg
3. RA 16 (12 mm Hg mean)
4. RV 45/11 mm Hg mean
5. PA 45/17 (32 mm Hg mean)
6. PCWP 19 mm Hg mean.
7. _____ oximetry run- SVC 71%, RA 84%, PA 88 4%, FA 91%
8. Systemic blood flow 6.14 liters per minute. Pulmonary blood flow 47 liters per minute, with Qp/Qs ratio 7 69 (assumed hemoglobin of 15 7 gm/dL, assumed oxygen consumption of 258 mL per minute)

Angiographic Findings:

Left Main: Normal. Has a very short left main

Left Anterior Descending: Normal

Left Circumflex: Left circumflex artery terminates into 3 large CM branches without any significant disease

Right Coronary Artery: Arising from a slightly anterior position in the right coronary cusp. This vessel has a very large conus branch arising almost in an anomalous fashion right at its origin, and supplies the right ventricle. This has multiple large branches. The main RCA and posterior descending arteries are free of significant disease. A multipurpose 5-French catheter was advanced and initially this wire went to an area outside the right atrial free border. In light of the above, anomalous pulmonary venous drainage was suspected. This multipurpose catheter was advanced, and pulmonary vein angiography was performed. This was the right upper pulmonary vein, draining normally into the left atrium and was not anomalous pulmonary vein. Subsequently, an intracardiac echocardiogram catheter was advanced and was parked in the right atrium, and detailed interrogation of the interatrial septum was performed using standard technique. There was a large secundum type atrial septal defect. There was no posterior rim detected in the midsegment. The anterior rim was adequate. In light of the above, we elected to assess the accurate sizing and flow cessation with a sizing balloon. An Amplatz Super-Stiff wire and subsequently a J-wire were parked in the left atrium, over which a 30 mm NMT sizing balloon was advanced and inflated across the interatrial septal. This balloon at 30 mm still had some residual minimal shunting on the posterior rim, and there was some give with motion. After detailed discussion with Dr. Benway, a pediatric interventional cardiologist, we elected to not proceed with any attempts at percutaneous device closure because of the above findings. All the equipment was removed, and access site hemostasis was to be achieved when ACT was less than 160 seconds.

Impression:
1. A large secundum-type atrial septal defect, and not suitable for percutaneous closure. 2. Elevated right heart filling pressure with mild pulmonary hypertension and significant left to right shunt at the atrial level (Qp/Qs ratio more than 7).
3. No significant epicardial coronary artery stenosis.

Plan and Recommendations: Mr. Lee’s detailed intracardiac echocardiography and the right and left heart catheterization confirm hemodynamically significant secundum-type atrial septal defect. Based on the technical factors delineated above, this will be best served with surgical closure. I will discuss the case with a cardiothoracic surgery colleague, and then proceed further as appropriate. He will require close follow up, and I have taken the liberty of adding low-dose ACE inhibitor therapy to optimize his perioperative outcomes from a remodeling standpoint.

ICD-10-CM code(s) __________________________________