Case 1 Physician Office Note S: The patient’s wife brought t
Case 1 Physician Office Note S: The patient’s wife brought the… Case 1Physician Office NoteS: The patient’s wife brought the patient to my office after the patient tried to separate a raccoon and their dog, which were fighting. While trying to separate the animals, the patient was bitten. He is not sure whether the raccoon or the dog bit him.EXAM:The patient’s left forearm has bite marks on it. The wound is bleeding and is deep, and there is tendon involvement.The nurse cleaned the wound, and a tetanus shot was given. Because the wound is deep and there is tendon involvement, I called Dr. Black for a surgical consult. The wound was dressed to control the bleeding.ICD-10-CM Code Assignment: Case 2ER NoteCHIEF COMPLAINT: This 2-year-old patient presents with a cut on his face.History of the present illness: Patient fell off a kitchen chair and struck his face on the seat of the chair.VITAL SIGNS: Pulse: 117, Respirations: 28, BP: 103/43RESPIRATORY: Airway clearBREATH SOUNDS: ClearSKIN: 1.5-cm laceration to the forehead.LACERATION REPAIR NOTE: The patient was papoosed with his mother’s knowledge and presence. The wound was injected with 2% plain Lidocaine, and the wound edges were approximated with three #6-0 nylon sutures.The patient was sent for an x-ray to rule out any facial bone fractures.PLAN: Follow up with family physician in 1 week.ICD-10-CM Code Assignment: Case 3Physician Office NoteCHIEF COMPLIANT: Pain in right arm.HISTORY OF PRESENT ILLNESS: This 39-year-old female was carrying groceries into her house when she slipped on ice and fell. She landed on her right side and on her arm.EXAM: EXTREMITIES: Her right arm is swollen, and it appears to be broken due to its abnormal appearance.An in-office x-ray was completed that showed a complete fracture of the shaft of the humerus. Patient was referred to Dr. Break, the orthopedic surgeon on call. Patient was sent to Dr. Break’s office.ICD-10-CM Code Assignment: Case 4Clinic Visit NoteThis is a 63-year-old type II diabetic male who presents 4 weeks after left foot amputation due to his diabetes. The patient presented to this office at the time of the injury due to concerns he had regarding possible complications stemming from his amputation, as his stump is quite red.Upon examination, there was no streaking at this time, but some clear drainage is noted. The patient is afebrile, and other vital signs are within normal limits.The diagnosis at this time is infection of amputation stump, left lower leg. We are starting the patient on antibiotics and have also treated and dressed the wound.ICD-10-CM Code Assignment: Case 5Emergency Department NoteThis patient is a 27-year-old male who was brought to the emergency department by ambulance after being bitten by a rattlesnake while hiking in the desert. The bite is located just above the ankle. The patient was wearing sneakers instead of hiking boots. The area of the bite is now red and a bit swollen.The patient says the pain is about 9 out of 10 on the pain scale.Examination reveals two small puncture marks on the medial side of the lower leg above the ankle.Vital signs are within normal limits. The skin is swollen, red, and warm to touch. Patient was given a shot of antivenom and admitted for 24-hour observation.ICD-10-CM Code Assignment: Case 6Office VisitThis 16-year-old male patient returns to the office today due to increased pain in his left upper leg. He had a previous traumatic fracture of the neck of the left femur. An x-ray was taken that showed a nonunion of the fracture.ICD-10-CM Code Assignment: Case 7Discharge NoteThis 34-year-old patient was admitted via the ED 3 days ago due to a traumatic rupture of the collateral ligament of the left wrist. Repair of the ligament was completed and the patient had no complications. She is instructed to see me in 2 weeks.ICD-10-CM Code Assignment: Case 8Emergency Department NoteThis female patient presents to the ER today with severe pain in her right index finger. She does not recall injuring the finger but there is a dislocation of the finger. I was able to manipulate the joint and realign it. I instructed her to follow up with orthopedics if more pain and discomfort occurs.ICD-10-CM Code Assignment: Case 9This 59-year-old male previously had knee surgery in his left knee with a prosthesis inserted. He comes to the office today complaining of pain. Imaging of the knee and blood work confirm an infection surrounding the prosthesis. He is being referred to orthopedics to discuss treatment and I have prescribed an antibiotic.ICD-10-CM Code Assignment: Case 10Office Visit NoteThis patient presents today complaining of discomfort in her lower back. X-ray shows no signs of fracture. She is able to move without difficultly. She does not recall any injury to her back.Vital Signs: BP: 120/80, Pulse: regularSkin: On exam there is a contusion on her left lower back.Heart: NormalLung: ClearExtremities: ROM within normal limits, no contusions or wounds noted.There are no other injuries noted at this time.ICD-10-CM Code Assignment: Health Science Science Nursing HIT MISC
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