Deck 15: Primary Case Studies

Question 1

Patient: John O'Rourke
From the Patient Information Form
Encounter Date: 10/04/2018
Diagnoses
The patient presents with angina upon exertion; coronary atherosclerosis is diagnosed.
Procedures
Saw this new patient in the office; referred the patient for a treadmill test. Performed a comprehensive history and exam, with moderately complex decision making.

Answer 1

Not Answer

Question 2

Patient: Sylvia Evans
From the Patient Information Form
Encounter Date: 10/15/2018
Diagnoses
The patient presents with postmenopausal bleeding due to estrogen deficiency.
Procedures
Saw this established patient in the office for a follow-up visit on her postmenopausal bleeding. Performed a problem-focused history and exam with straightforward decision making.
Medisoft Tip
Note that Sylvia Evans already has a set of transactions in the database for her visit on 10/11/2018. Enter the new transactions (for 10/15/2018) in the Transaction Entry dialog box under the previous transactions. When applying the $10 copayment for the second visit, make sure to apply it to the procedure code with the 10/15/2018 date.

Answer 2

Not Answer

Question 3

Patient: Wendy Walker

Answer 3

Not Answer

Question 4

Patient: Karen Giroux
From the Patient Information Form
Encounter Date: 10/04/2018
Diagnoses
The patient presents for a routine annual physical.
Procedures
Saw this new patient in the office for her annual examination.

Question 5

Patient: Walter Williams

Question 6

Patient: Jean Ruff
From the Patient Information Form
Encounter Date: 10/03/2018
Diagnoses
The patient complains of a spiking fever and chills for three days.
Procedures
Saw this new patient in the office. Performed an expanded problem-focused history and exam with low-complexity decision making. Following the finding of a bulls-eye rash on the patient's left shoulder, ordered a Borrelia test tomorrow for suspected Lyme disease.

Question 7

Patient: Donna Gaeta

Question 8

Patient: Mary Anne Kopelman
From the Patient Information Form
Encounter Date: 10/03/2018
Diagnoses
The patient presents with fatigue.
Procedures
Saw this new patient in the office. Detailed history and exam, with low-complexity decision making; urinalysis.

Question 9

Patient: Lakshmi Prasad

Question 10

Patient: Otto Kaar
From the Patient Information Form
Encounter Date: 10/04/2018
Diagnoses
The patient presents with a carbuncle on the left thumb.
Procedures
Saw this new patient in the office; incised and drained this single abscess.

Question 11

Patient: Joseph Zylerberg

Question 12

Patient: Shih-Chi Yang
Workers' Compensation Notes

Question 13

Patient: Andrea Spinelli

Question 14

Patient: Nancy Lankhaar

Question 15

Patient: Donald Aiken

Question 16

Patient: Eric Huang

Question 17

Patient: Isabella Neufeld
From the Patient Information Form
Encounter Date: 10/01/2018
Diagnoses
The patient presents with urticaria following prolonged exposure to recent cold weather conditions.
Procedures
Saw this new patient in the office. Performed a problem-focused history and exam with straightforward decision making.

Question 18

Patient: Alan Harcar
From the Patient Information Form
Encounter Date: 10/01/2018
Diagnoses
The patient presents with an upper respiratory infection.
Procedures
Saw this new patient in the office. Performed an expanded problem-focused history and exam with low-complexity decision making.

Question 19

Patient: Jose Velaquez
From the Patient Information Form
Encounter Date: 10/03/2018
Diagnoses
Following an office visit with further workup, the patient's diagnosis is mitral valve stenosis due to rheumatic heart disease.
Procedures
Saw this new patient in the office. Performed a comprehensive history and exam with moderate-complexity decision making. Also completed a rhythm ECG with a report.

Question 20

Patient: Wilma Estephan
From the Patient Information Form
Encounter Date: 10/03/2018
Diagnoses
The patient presents for a checkup on her benign hypertension.
Procedures
Saw this established patient in the office for a second checkup on her blood pressure after a six-month prescription of an ACE inhibitor. The presenting problem was minimal.