Exam (elaborations)
AAPC CHAPTER 19 QUESTIONS AND ANSWERS WITH SOLUTIONS 2024
AAPC CHAPTER 19 QUESTIONS AND ANSWERS WITH SOLUTIONS 2024
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AAPC CHAPTER 19 QUESTIONS ANDANSWERS WITH SOLUTIONS 2024
NEWNPATIENTNOFFICENVISIT
CHIEFNCOMPLAINT:NRightNinguinalNhernia.N
HISTORYNOFNPRESENTNILLNESS:NThisN44-year-
oldNathleticNmanNhasNbeenNawareNofNaNbulgeNandNaNpainNinNhisNrightNgroinNforNoverNaNyear.NHeNisNveryNacti
ve,NbothNaerobicallyNandNanaerobically.NHeNhasNaNweightNroutineNwhichNheNhasNmodifiedNbecauseNofNthisN
bulgeNinNhisNrightNgroin.NUsually,NheNcanNcompleteNhisNentireNworkout.NHeNcanNswimNandNworkNwithoutNpr
oblems.NSeveralNweeksNago,NinNtheNshower,NheNnoticedNthereNwasNaNbulgeNinNtheNgroinNandNheNwasNableNt
oNpushNonNitNandNmakeNitNgoNaway.NHeNhasNneverNhadNaNgroinNoperationNonNeitherNside.NTheNpainNisNmini
mal,NbutNitNisNuncomfortableNandNitNlimitsNhisNabilityNtoNparticipateNinNhisNphysicalNactivityNroutine.NInNadd
ition,NheNlikesNtoNdoNaNlotNofNexerciseNinNtheNbackNcountryNandNhisNpersonalNphysician,NDr.NX,NtoldNhimNtha
tNitNwouldNbeNdangerousNtoNhaveNthisNbecomeNincarceratedNinNtheNbackNcountry.
PASTNMEDICALNHISN-NANSWERN99203
N
Rationale:
NewNPatient
NumberNandNComplexityNofNProblemsN-NOneNacuteNuncomplicatedNillnessNorNinjuryN-NLow
AmountNand/orNComplexityNofNDataNtoNbeNReviewedNandNAnalyzedN-NNone
MedicalNdecisionNmakingN-NelectiveNmajorNsurgery,NnoNidentifiedNriskNfactorsN-NModerate
John,NaN16-year-
oldNmale,NisNadmittedNbyNtheNemergencyNdepartmentNphysicianNforNobservationNafterNanNATVNaccident.NT
heNpatientNisNdischargeNfromNobservationNbyNanotherNproviderNtheNnextNday.NWhatNcategoryNorNsubcateg
oryNofNevaluationNandNmanagementNcodesNwouldNbeNselectedNforNtheNemergencyNdepartmentNphysician?
N-NANSWERNInitialNobservationNcare
Rationale:NTheNpatientNpresentedNtoNtheNEmergencyNDepartmentNandNwasNadmittedNtoNobservationNbyNt
heNEDNphysician.NTheNguidelinesNforNInitialNObservationNCareNstateNthatNallNservicesNprovidedNbyNtheNadmi
ttingNphysicianNforNtheNsameNdateNofNserviceNareNincludedNinNtheNinitialNhospitalNcare,NandNinNthisNinstanc
eNtheNemergencyNdepartmentNservicesNwouldNnotNbeNcoded.NIfNtheNpatientNwasNdischargedNonNtheNsameN
dateNofNservice,NaNcodeNfromNObservationNorNInpatientNCareNServicesN(IncludingNAdmissionNandNDischarg
eNServices)NwouldNbeNselected.
,DuringNaNsoccerNgame,NAshley,NaN26-year-
oldNfemale,NheardNaNpoppingNsoundNinNherNknee.NHerNkneeNhasNbeenNunstableNsinceNtheNincidentNandNsh
eNdecidedNtoNconsultNanNorthopedist.NSheNvisitsNDr.NHoward,NanNorthopedistNsheNhasNnotNseenNbefore,NtoN
evaluateNherNkneeNpain.NDr.NHoward'sNdiagnosisNisNaNtornNACL.NFromNwhatNcategoryNorNsubcategoryNofNev
aluationNandNmanagementNcodeNwouldNbeNselectedNforNtheNvisitNtoNDr.NHoward?N-
NANSWERNOfficeNvisit,NnewNpatient
Rationale:NConsultationsNperformedNatNtheNrequestNofNaNpatientNareNcodedNusingNofficeNvisitNcodes.NBeca
useNtheNpatientNhasNnotNseenNDr.NHowardNbefore,NthisNwouldNbeNconsideredNaNnewNpatientNvisit.
TheNpatientNisNseenNinNtheNnursingNhomeNtodayNforNaNfollowNupNofNhisNhospitalizationNforNpneumonia.NHeN
wasNplacedNbackNonNSingulair®NandNhasNbeenNimprovingNwithNhisNbreathingNsinceNthen.NWhatNisNtheNlevel
NofNhistory?N-NANSWERNProblemNfocused
EmergencyNDepartmentAN47-year-
oldNwhiteNmaleNpresentsNtoNtheNemergencyNdepartmentNafterNtheNfour-
wheelerNheNwasNoperatingNstruckNaNditchNandNrapidlyNcameNtoNaNhalt.NThisNthrewNhimNagainstNtheNwindsh
ieldNwhereNheNstruckNtheNmidNpartNofNhisNfaceNandNlowerNlip.NThisNresultedNinNlipNandNchinNlacerations.NHe
NisNevaluatedNbyNDr.NJonesNandNaNCTNscanNsuggestsNaNhyperNdenseNabnormalityNwithinNtheNbrain.NANbleedN
couldNnotNbeNruledNoutNandNanNinpatientNhospitalNadmissionNisNrecommended.
HisNpastNhistoryNincludesNpreviousNtonsillectomy,NpreviousNhospitalNadmissionNforNaNsyncopalNepisodeNass
ociatedNwithNpainNinNtheNgroinNarea,NandNhypercholesterolemia.NHeNhasNnoNknownNallergies.NHisNcurrentN
medicationsNareNZocor®NandNAccutane®.NHeNisNaNnon-
smokerNandNaNmoderateNdrinkerNofNalcohol.TheNreviewNofNsystemsNisNnegativeNforNnausea,Nvomiting,Nblur
redNvision,NorNheadache.
WhatNisNtheNlevelNofNhistory?N-NANSWERNExpandedNproblemNfocused
PhysicalNExam:
GENERALNAPPEARANCE:NHealthyNappearingNindividualNinNnoNdistress
ABDOMEN:NSoft,Nnon-tender,NwithoutNmasses.NNoNCVANtenderness
FEMALENEXAM:
VULVA/LABIANMAJORA:NNoNerythema,Nulcerations,Nswelling,NorNlesionsNseen.
BARTHOLINNGLANDS:NNoNcysts,Nabscesses,Ninduration,Ndischarge,Nmasses,NorNinflammationNnoted.
SKENE'S:NNoNcysts,Nabscesses,Ninduration,Ndischarge,Nmasses,NorNinflammationNnoted.
, CLITORIS/LABIANMINORA:NClitorisNnormal.NNoNatrophy,Nadhesions,Nerythema,NorNvesiclesNnoted.NLabiaNun
remarkable.
URETHRALNMEATUS:NMeatusNappearsNnormalNinNsizeNandNlocation.NNoNmasses,NlesionsNorNprolapse.
URETHRA:NNoNmasses,NtendernessNorNscarring.
BLADDER:NWithoutNfullness,NmassesNorNtenderness.
VAGINA:NMucosaNclearNwithoutNlesions,NPelvicNsupportNnormal.NNoNdischarge.
CERVIX:NTheNcervixNisNclear,NfirmNandNclosed.NNoNvisibleNlesions.NNoNabnormalNdischarge.
UTERUS:NUterusNnon-tenderNandNofNnormalNsize,NshapeNandNconsistenN-NANSWERNComprehensive
Rationale:NOrganNSystems:NTheNdocumentationNsupportsNaNcomprehensive/completeNsingleNsystemN(Fem
aleNGenitourinary)Nexam.NTheNlevelNofNexamNisNComprehensive.
PhysicalNExam:
CONSTITUTIONAL:NVitalNSigns:NPulse:N161.NResp:N30.NTemp:N102.4.NOxygenNsaturationN90%NGENERALNAPP
EARANCE:NTheNpatientNrevealsNprofoundNmentalNretardation.NTracheostomyNisNinNplace.NEYES:NConjunctiv
aeNareNslightlyNanemic.NENT:NOralNmucosaNisNdry.NNECK:NTheNneckNisNsuppleNandNtheNtracheaNisNmidline.NR
angeNofNmotionNisNnormal.NThereNareNnoNmasses,NcrepitusNorNtendernessNofNtheNneck.NTheNthyroidNglandN
hasNnoNappreciableNgoiter.NRESPIRATORY:NTheNlungsNrevealNtransmittedNupperNairwayNsignsNandNbilateralN
rales,NwheezesNandNrhonchi.NCARDIOVASCULAR:NTheNchestNwallNisNnormalNinNappearance.NRegularNrateNa
ndNrhythm.NNoNmurmurs,NrubsNorNgallopsNareNnoted.NThereNisNnoNsignificantNedemaNtoNtheNlowerNextremi
ties.NGASTROINTESTINAL:NTheNabdomenNisNsoftNandNnondistended.NThereNisNnoNtenderness,NreboundNorN
guardingNnoted.NThereNareNnoNmasses.NNoNorganomegalyNisNappreciated.NSKIN:NTheNskinNisNpaleNandNsligh
tlyNdiaphoretic.N-NANSWERNComprehensive
Rationale:NOrganNSystems:NConstitutional,NEyes,NENMT,NRespiratory,NCardiovascular,NGastrointestinal,NInte
gumentary,NNeurologic,NLymphatic,NMusculoskeletal.NTenNorganNsystemsNwereNexamined.NTheNlevelNofNex
amNisNComprehensive.
HospitalNvisit
CHIEFNCOMPLAINT:NGallstonesNandNreflux.
HISTORYNOFNPRESENTNILLNESS:NThisNisNaN61-year-
oldNwomanNwhoNwasNseenNinNtheNERNandNsubsequentlyNadmittedNinNobservationNstatus.NSheNhasNaNtwo-
yearNhistoryNofNsevereNgallbladderNattacks.NAlsoNofNnote,NsheNhasNhadNongoingNrefluxNproblemsNforNmanyN
years.NWithinNtheNlastNfewNmonths,NherNrefluxNhasNworsened.
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