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Z31.41 - Encounter for sperm count for fertility testing
N46.9 - Male infertility
N46.1 - Oligospermia
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SAGE MINDTAP Q Search this Yourself Click for Transcript Physician Office Note This 38-year-old male returns...
Office Note This 78-year-old male returns to the office today to follow-up on diagnostic testing completed...
Office Note This 78-year-old male returns to the office today to follow-up on diagnostic testing completed due to his ongoing muscle aches, myalgia, stiffness, and muscle weakness. Laboratory testing: Urinalysis was positive for hemoglobin. The urine myoglobin test and serum myoglobin test were both positive. The serum CPK value was high. Following these values additional testing was completed that confirmed elevated muscle enzymes in the blood. Because of these findings a diagnosis of rhabdomyolsis was confirmed. Plan: I discussed with...
1- Inpatient Visit Physician Note S: This 92-year-old male patient was admitted 2 days ago due...
1- Inpatient Visit Physician Note S: This 92-year-old male patient was admitted 2 days ago due to a sudden onset of fever, headache, and complaining of a very stiff neck. The patient took Tylenol at home to relieve his headache but it did not relieve the headache. When his fever reached 101 his daughter brought him to the emergency department and he was admitted. Testing confirmed meningitis.O: Respirations are 32. Pulse is 100. BP: 130/90. He is alert and in...
Inpatient Physician’s Progress Note This 2-day-old infant examined today to follow-up after the results of diagnostic...
Inpatient Physician’s Progress Note This 2-day-old infant examined today to follow-up after the results of diagnostic tests. Blood gas: Study indicates reduced oxygen tension and ineffective gas exchange. Chest X-ray: presence of infiltrate Infant continues to exhibit signs of infant respiratory distress syndrome, type 2. Orders: Continue titrated oxygen and aerosol infusion of Survanta. What is the correct ICD-10-CM diagnostic code(s) for this case? .......X.......... Physician Office Note This 15-year-old male patient presents today to monitor his congenital stenosis of...
Case 1 Clinic Note This 57-year-old female patient comes to the clinic today for her annual...
Case 1 Clinic Note This 57-year-old female patient comes to the clinic today for her annual physical. HEENT: Normal LUNGS: Clear ABDOMEN: Soft, nontender RECTAL EXAM: Refused NEUROLOGICAL: Congenital spastic paralysis, left leg There are no physical findings that need to be addressed at this time. I have reviewed her care plan, and she should continue per her care plan at the residential home where she resides. ICD-10-CM Code Assignment.....x........ Case 2 Sleep Clinic Note This patient returns today following...
The following documentation is from the health record of a 42-year-old male patient. Physician Office Record...
The following documentation is from the health record of a 42-year-old male patient. Physician Office Record Entries Hospital Copy: History and Physical Admitting Diagnosis: Herniation of intervertebral disc, L5–S1 right side Present Medical History: Patient is a 42-year-old Native American male who initially developed problems with his back in July of this year. He was treated with anti-inflammatory agents and started on an exercise program; his condition improved enough to return to work. About one month ago, he had recurrence...
The following documentation is from the health record of a 42-year-old male patient. Physician Office Record...
The following documentation is from the health record of a 42-year-old male patient. Physician Office Record Entries Hospital Copy: History and Physical Admitting Diagnosis: Herniation of intervertebral disc, L5–S1 right side Present Medical History: Patient is a 42-year-old Native American male who initially developed problems with his back in July of this year. He was treated with anti-inflammatory agents and started on an exercise program; his condition improved enough to return to work. About one month ago, he had recurrence...
Case 1 Clinic Note This 57-year-old female patient comes to the clinic today for her annual physical. HEENT: Normal LUNG...
Case 1 Clinic Note This 57-year-old female patient comes to the clinic today for her annual physical. HEENT: Normal LUNGS: Clear ABDOMEN: Soft, nontender RECTAL EXAM: Refused NEUROLOGICAL: Congenital spastic paralysis, left leg There are no physical findings that need to be addressed at this time. I have reviewed her care plan, and she should continue per her care plan at the residential home where she resides. ICD-10-CM Code Assignment.....x........ Case 2 Sleep Clinic Note This patient returns today following...
Mr. Smith, a 50-year-old male presents to the office for a comprehensive physical. His blood pressure...
Mr. Smith, a 50-year-old male presents to the office for a comprehensive physical. His blood pressure reading is 162/110 mmHg, with an apical pulse rate of 79 beats/min and regular. He has a history of smoking and drinking six beers per night. He is 5’8" and 230 lbs. Mr. Smith works as a prison guard. He is not previously diabetic but has not had a physical exam since age 25, upon discharge from the military. He has a family history...
You are working the medical-surgical unit and have been assigned a 42-year-old male patient who has...
You are working the medical-surgical unit and have been assigned a 42-year-old male patient who has had a colon resection with colostomy two days ago. His history includes diabetes, colon cancer, and hypertension. His abdominal incision was assessed with this morning’s dressing change. His vital signs are within normal range for him and he shows no signs of surgical incision infection at this time. He lives at home with his wife and has two teenage children still at home. He...
LOCATION: Hospital Emergency Department PATIENT: Dillon Watkins PHYSICIAN: Paul Sutton, M.D. SUBJECTIVE: 13-year-old white male, no...
LOCATION: Hospital Emergency Department PATIENT: Dillon Watkins PHYSICIAN: Paul Sutton, M.D. SUBJECTIVE: 13-year-old white male, no ongoing medical problems, takes no medications, and no known allergies. He presents to the Emergency Room with a jamming injury (catching football) to his left third finger he sustained while playing football. Complains of pain at the PIP joint. NEUROMUSCULOSKELETAL REVIEW OF SYSTEMS: No paresthesias. OBJECTIVE: He has slight swelling and tenderness of the PIP joint. He has full range of motion and the...
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