Chapter 1: Evaluation and Management
Case 1-1: Discharge Summary, Chest Pain
Case 1-2: Progress Note, Renal
Case 1-3: Progress Note, Hypotension
Case 1-4: Discharge Summary, Cardiac Catheterization
Case 1-5: Nephrology Consultation, Hypertension
Case 1-6: Nephrology Consultation, Hypotension
Case 1-7: Discharge Summary, Acute and Chronic Renal Failure
Case 1-8: Discharge Summary, Hypotension
Case 1-9: Progress Note, Hemoptysis
Case 1-10: Neurosurgery Consultation, Neck Injury
Case 1-11: Neurosurgery Consultation, Neck Pain
Case 1-12: Neurosurgery Consultation, Leg Pain
Case 1-13: Consultation, Intracerebral Hematoma
Case 1-14: Rehabilitation Consultation, Back Pain and SOB
Case 1-15: Urology Consultation, Oliguria
Case 1-16: Thoracic Medicine/Critical Care Progress Note, Lung Cancer
Case 1-17: Clinic Visit, Diarrhea
Case 1-18: Cardiology Consultation, Chest Pain and SOB
Case 1-19: Clinic Visit, Abdominal Pain
Chapter 2: Anesthesiology
Case 2-1: Perforated Appendicitis
Case 2-2: Right Inguinal Herniorrhaphy
Case 2-3: Laparoscopic Cholecystectomy
Case 2-4: Left Breast Biopsy
Case 2-5: Amputation
Case 2-6: Umbilical Herniorrhaphy
Case 2-7: Takedown Colostomy and Cholecystectomy
Case 2-8: Modified Radical Mastectomy
Case 2-9: Incision And Drainage Of Perirectal Abscess
Case 2-10: Division and Insetting of Flap
Case 2-11: Intracerebral Hematoma
Chapter 3: Cardiology
Case 3-1: Catheter Placement
Case 3-2: Chart Note, Therapeutic Apheresis
Case 3-3: Catheterization
Case 3-4: Coronary Artery Bypass Graft
Case 3-5: Intubation
Case 3-6: Dressing Change and Oversewing of Tracheostomy
Case 3-7: Thoracentesis
Case 3-8: Endarterectomy
Case 3-9: Angiogram
Case 3-10: Intra-aortic Balloon Pumping
Chapter 4: Integumentary
Case 4-1: Excision, Cheek Lesion
Case 4-2: Right Breast Wide Excision
Case 4-3: Thenar Flap Coverage
Case 4-4: Division and Insert of Flap
Case 4-5: Laceration Repair
Case 4-6: Massive Debridement
Case 4-7: Minimal Debridement
Case 4-8: Amputation
Case 4-9: Nevus Excision
Chapter 5: Emergency Medicine
Case 5-1: Forearm Abrasion and Swelling
Case 5-2: Vomiting
Case 5-3: Gastroesophageal Reflux Disease
Case 5-4: Headache
Case 5-5: Closed Head Injury
Case 5-6: Sore Throat, Earache, and Sore Chest
Case 5-7: Thigh Redness
Case 5-8: Patellar Dislocation
Case 5-9: Leg Laceration
Case 5-10: Abdominal Pain and Diarrhea
Case 5-11: Scrotal Bleeding
Case 5-12: Dyspnea and Tachycardia
Chapter 6: Medicine
Case 6-1: Echocardiogram
Case 6-2: Stress Test
Case 6-3: Cardiac Catheterization
Case 6-4: Cardiac Catheterization
Case 6-5: Right Heart Catheterization
Case 6-6: Bilateral Laser-Doppler
Case 6-7: Saphenous Vein Mapping
Case 6-8: Venous Ultrasound
Case 6-9: Extremities Ultrasound
Case 6-10: Renal Dialysis Progress Note
Chapter 7: Gastroenterology
Case 7-1: Orogastric Tube Placement
Case 7-2: Splenectomy and Colectomy
Case 7-3: Gastrojejunostomy Placement
Case 7-4: Cystotomy
Case 7-5: Small Bowel Anastomosis
Case 7-6: Pyloroplasty
Chapter 8: Nephrology
Case 8-1: Progress Note, Dialysis
Case 8-2: Progress Note, Peritoneal Dialysis
Case 8-3: Progress Note, Cycler PD
Case 8-4: Renal Tumor Excision
Case 8-5: Renal Mass
Case 8-6: Renal Tumor
Case 8-7: Dialysis Catheter Replacement
Chapter 9: Neurology and Ophthalmology
Case 9-1: Intracerebral Hematoma
Case 9-2: Release Of Ulnar Nerve and Cubital Tunnel
Case 9-3: Parietal Burr Holes
Case 9-4: Discectomy
Case 9-5: Carpal Tunnel
Case 9-6: Repair of Pseudomeningocele
Case 9-7: Laminectomy with Foraminotomy
Case 9-8: Laminotomy, Discectomy, and Foraminotomy
Case 9-9: Halo Crown and Vest
Case 9-10: Extracapsular Cataract
Chapter 10: Obstetrics and Gynecology
Case 10-1: Abdominal Hysterectomy
Case 10-2: Dilation and Curettage
Case 10-3: Cesarean Section
Case 10-4: Labial Excision
Case 10-5: Dilation and Curettage
Case 10-6: Cervical Cerclage Preoperative Examination
Case 10-7: Suction Dilation and Curettage
Case 10-8: Cesarean with Tubal Ligation
Case 10-9: Cesarean Section
Case 10-10: OB Ultrasound
Case 10-11: Laparoscopic Drainage of Cyst
Chapter 11: Orthopedics
Case 11-1: Arthroplasty and Spur Excision
Case 11-2: Meniscectomy, Knee
Case 11-3: Plical Excision
Case 11-4: Medial Meniscectomy, Knee
Case 11-5: Steroid Injection
Case 11-6: Open Reduction Internal Fixation
Case 11-7: Fascial Sling Arthroplasty
Case 11-8: Excision Bone Tumor
Case 11-9: Carpal Tunnel Release
Case 11-10: Debridement of Chondromalacia
Case 11-11: Excision of Mass, Bursa
Case 11-12: Excision Of Mass, Finger
Case 11-13: Arthroplasty, Hip
Chapter 12: Otorhinolaryngology
Case 12-1: Tympanostomy
Case 12-2: Direct Laryngoscopy
Case 12-3: Myringotomy with Tympanostomy
Case 12-4: Adenoidectomy
Case 12-5: Tonsillectomy and Adenoidectomy
Case 12-6: Esophagoscopy with Dilation
Case 12-7: Cervical Node Excision
Case 12-8: Septoplasty
Case 12-9: Mandibular Angle Fracture
Case 12-10: Brachial Cleft Fistula Repair
Case 12-11: Incus and Stapes Mobilization
Case 12-12: Ethmoidectomy, Sphenoidotomy, and Septoplasty
Case 12-13: Tarsorrhaphy
Chapter 13: Pathology
Case 13-1: L3-L4 Disc
Case 13-2: Uterus, Bilateral Tubes, and Ovaries
Case 13-3: Placenta
Case 13-4: Cervical Disc
Case 13-5: Cervical Disc
Case 13-6: Endometrial Curettage
Case 13-7: Cerebral Hematoma
Case 13-8: Necrotic Fascia
Case 13-9: Myxoma
Case 13-10: Soleus Muscle
Chapter 14: Pediatrics, Neonatology, and Adolescent Medicine
Case 14-1: Well-Child Check
Case 14-2: NICU Progress Note, Prematurity with Respiratory Difficulty
Case 14-3: Progress Note, Ventilator Assist
Case 14-4: NICU Progress Note, Ventilator Assist
Case 14-5: Circumcision
Case 14-6: Newborn Report
Chapter 15: Diagnostic Radiology
Case 15-1: CT of Brain
Case 15-2: X-Ray, Chest
Case 15-3: Cranial CT
Case 15-4: X-Ray, Chest
Case 15-5: CT of Abdomen and Pelvis
Case 15-6: Gallbladder Ultrasound
Case 15-7: Ultrasound, Kidneys
Case 15-8: Catheter Placement
Case 15-9: Stress Test
Case 15-10: Ventilation-Perfusion Lung Scan
Case 15-11: Head Ultrasound
Case 15-12: Abdominal X-Ray, UVC Catheter Placement
Case 15-13: Neonatal Cystourethrogram
Chapter 16: Intervention Radiology and Radiation Oncology
Case 16-1: CT-Guided Liver Biopsy
Case 16-2: CT-Guided Lung Mass Biopsy
Case 16-3: Lumbar Puncture
Case 16-4: Ultrasound-Guided Paracentesis
Case 16-5: Catheter Placement
Case 16-6: Carotid Angiogram
Case 16-7: Aortogram
Case 16-8: Tube Placement
Case 16-9: Fistulogram
Case 16-10: Extremity Angiogram
Case 16-11: Abdominal Aortogram
Case 16-12: Inpatient Consultation, Radiology Oncology
Case 16-13: Treatment Planning Note, Radiation Oncology
Case 16-14: Simulation Note, Radiation Oncology
Chapter 17: Urology
Case 17-1: Native Kidney Biopsy
Case 17-2: Cystoscopy
Case 17-3: Catheterization
Case 17-4: Cystoscopy and Retrograde Pyelogram
Case 17-5: Kidney Biopsy
Case 17-6: Native Kidney Biopsy
Case 17-7: Ureteral Stent Change
Case 17-8: Multiple Bladder Biopsies
Case 17-9: Fulguration and Penile Lesion Biopsy
Case 17-10: Hydrocele Repair
Chapter 18: General Surgery
Case 18-1: Perforated Appendicitis
Case 18-2: Right Inguinal Herniorrhaphy
Case 18-3: Laparoscopic Cholecystectomy
Case 18-4: Stab Wound
Case 18-5: Left Breast Biopsy
Case 18-6: Amputation
Case 18-7: Umbilical Herniorrhaphy
Case 18-8: Colostomy and Cholecystectomy
Case 18-9: Modified Radical Mastectomy
Case 18-10: Incision and Drainage of Perirectal Abscess
Case 18-11: Peritoneal Dialysis Catheter Placement
Appendix: Coding Answers to Patient Cases