1. A 54-year-old patient is seen by the physician in the outpatient clinic setting for CLL that is currently in remission. The patient's WBC counts, particularly lymphocytes remain within normal limits 2. Susan Oster, 45, is admitted to the hospital with a temperature of 38.5º C, heart rate 102 beats/min, respiration 20/min with septicemia and SIRS. WBC 12,500. Documentation states respiratory and acute hepatic failure are due to septicemia. 3. OPERATIVE REPORT
PATIENT: Mara Bell Lee
PHYSICIAN: Randy Greenfield,
MD PREOPERATIVE DIAGNOSIS: Pleural effusion with unknown cause.
POSTOPERATIVE DIAGNOSIS: Pleural effusion with unknown cause.
PROCEDURES PERFORMED:
Diagnostic thoracentesis.
Four-quadrant pleural biopsy,
Pleural …show more content…

The three ports had good blood return, and the three of them were flushed with normal saline.The line was secured to the skin.The patient tolerated the procedure well without any immediate complications, and chest x-ray was ordered.I
CD-9-CM Code:__________________

5. and 6. OFFICE VISIT
PATIENT: Milly Mortonson
PHYSICIAN: Donald Grossman, MD CHIEF COMPLAINT: Hypothyroidism.SUBJECTIVE: Milly is a 39-year-old, established patient who is a married white female with a history of hypothyroidism. The TSH level done in May of 2000 was mildly elevated at 12.37. Since then, the patient has been taking an increased dose of Synthroid at 0.125 mcg daily. Except for her weight, she reports that she is feeling quite well. She is frustrated that she has gained weight over the summer. OBJECTIVE: Weight is 180 pounds. No other examination is done today during this problem-focused encounter.
ASSESSMENT: 1. Hypothyroidism, euthyroid on treatment.2. Weight gain.PLAN: She will continue on brand name Levothroid (this is the brand carried by the hospital) 0.125 mcg daily. The patient was given some information on a weight loss and walking program put on through the Public Health Department. Medical decision making at a straightforward level. Return clinic visit p.r.n.
ICD-9-CM Codes: 5. __________________ and 6. __________________

7. OPERATIVE REPORT PATIENT: Ann Zantza
PHYSICIAN: Dennis Munoz, MD PREOPERATIVE DIAGNOSIS: Cancer of