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Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
EMERGENCY
DEPARTMENT RECORD
PATIENT INFORMATION :
NAME : MILLER, Stella PATIENT NUMBER: EDCase051
ADDRESS: 2 Mill Street ADMISSION DATE & TIME : 12-02-YYYY 0950
CITY : Alfred DISCHARGE DATE & TIME : 12-02-YYYY 1750
STATE: NY
ZIP CODE: 14802
TELEPHONE: 607-587-8678
GENDER: Female
DATE OF BIRTH : 07-29-YYYY
CONDITION ON DISCHARGE :
R Satisfactory £ AMA
£ Home £ DOA
£ Inpatient Admission £ Code Blue
£ Transfer to: £ Died
R Instruction Sheet Given
NURSING DOCUMENTATION :
ALLERGIES: £No R Yes EXPLAIN: Penicillin
CURRENT MEDICATIONS: £No R Yes EXPLAIN: BCP
BP: 102/62 P: 88 R: 18 T: 37.6
CC: RLQ pain, nausea, vomiting, and chills
HPI: 1130 pm sudden onset R mid RLQ pain ? nausea Ø vomiting Ø urinary sx, ?
chills, Soft normal stool this am – denies any ? strenuous activity Ø vaginal
discharge
PMH: FX ankle
CONDITION :
ASSESSMENT: Due VO Dr. England ? DV to SL
SIGNATURE OF PRIMARY CARE NURSE: S.K. Sullivan, RN
ICD CODES:
CPT/HCPCS LEVEL II CODES:
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
EMERGENCY DEPARTMENT
NURSING DOCUMENTATION
PATIENT NAME : MILLER, Stella PATIENT NUMBER: EDCase051
LOCATION: Emergency Room ED PHYSICIAN: Frederick England, M.D.
DATE OF SERVICE: 12-02-YYYY DATE OF BIRTH 07-29-YYYY
Progress Notes:
TIME TREATMENTS/O BSERVATIONS
12-02
1010
Orthostatics done as noted Pt a&o x 3, mae well, Lump UA, abd soft, NT ? BS all 4
Quads. Afebrile. UA obtained. BP: 132/82 AP: 76
1020 1st attempt IV #20 1″ initiated R H, site without swelling/redness. Labs obtained via IV
NS bolus 300cc to be followed @ rate 150cc/hr BP: 102/62 AP: 88
1105 for rid pain 4/10 MSO4 4 mg IV
1110 Pelvic exam done by Dr. England. Cultures obtained.
1115 Starting to feel relief from pain BP: 120/72 AP: 72 R: 16
1145 Pt in ultrasound
1215 Ret. from ultrasound. Color unremarkable. Skin W & D Still has RLQ abd pain. sharp “4”
1225 Naprosyn 500 mg w/ milk
1250 More comfortable
1500 Color unremarkable. Skin W & D. C.T. explained. Fairly comfortable. Drank contrast.
BP: 120/70 AP: 72 R: 16
SIGNATURE OF ED NURSE S.K. Sullivan, RN
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
EMERGENCY DEPARTMENT
PHYSICIAN DOCUMENTATION
PATIENT NAME : MILLER, Stella PATIENT NUMBER: EDCase051
LOCATION : Emergency Room ED PHYSICIAN: Frederick England, M.D.
DATE OF SERVICE: 12-02-YYYY DATE OF BIRTH 07-29-YYYY
Physician Notes:
SEE TRANSCRIBED REPORT
Diagnosis: R ovarian cyst
Physician Orders:
UA CBC w/ diff, Amylase, HCG Orthostatics NPO
IV: NS 300 cc bolus then 150 cc/hr MSO4 4 mg IV x 1 Pelvic U/S R admexa; [aom
R/O cyst GC, Chlamydia
v.o. Dr. England to
Naprosyn 500 mg po CT of abd – RLQ pain R/O Appendicitis
Naprosyn 500 mg #2 to go
Vicodin 6 pack to go
SIGNATURE OF ED PHYSICIAN Frederick England
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
EMERGENCY DEPARTMENT
PHYSICIAN DOCUMENTATION
PATIENT NAME : MILLER, Stella PATIENT NUMBER: EDCase051
LOCATION : Emergency Room ED PHYSICIAN: Frederick England, M.D.
DATE OF SERVICE: 12-02-YYYY DATE OF BIRTH 07-29-YYYY
Emergency Department Notes:
SUBJECTIVE: Mrs. Miller is a 39-year-old white female who comes in because of right lower quadrant pain. The
patient about 11:30 last night had the sudden onset of right-sided lower quadrant and inguinal pain associated with nausea,
but no vomiting. The pain has been sharp and steady since that time and increased somewhat today. She has had no
urinary symptoms, no vaginal discharge and had a normal stool this morning. She has had no recent pain with intercourse.
She denies any increased activity or injury.
PAST MEDICAL HISTORY: Significant for an ankle fracture in the past.
CURRENT MEDICATIONS: Birth control pills.
PHYSICAL EXAMINATION: Vital signs: Blood pressure 132/82 lying with a pulse of 76. Blood pressure 102/62
standing with a pulse of 88. The patient was not dizzy.
Lungs: Resonant and clear to both bases. There is no CVA tenderness.
Heart: Normal Sl and S2 without murmur or gallop.
Abdomen: Soft and nontender except for tenderness in the extreme right lower quadrant area.
Pelvis: Moderate cervical motion tenderness. The patient has marked adnexal tenderness on the right, but no significant
tenderness on the left. Ovaries were not felt to be enlarged.
Rectal: Brown heme negative stool.
LABORATORY DATA: A white count of 9000, hematocrit 36.2 and a normal platelet count. Urinalysis is
unremarkable . HCG is negative. Amylase is 63.
EMERGENCY DEPARTMENT COURSE: The patient received IV normal saline vigorously as well as morphine IV.
The patient had a pelvic ultrasound to rule out a cyst, however, no cyst or free fluid was seen. After a discussion with Dr.
Siegrist, the patient had a CT of the abdomen to rule out appendicitis and this showed a left ovarian cyst, but no cyst on
the right. Of note, the patient also had some uterine fibroids seen.
IMPRESSION: Most likely that the patient did in fact still have a ruptured ovarian cyst on the right. There is no evidence
of active bleeding at the current time.
PLAN: The plan is to discharge the patient home on Naprosyn 500 mg q.12h. and Vicodin as needed for pain. She is to
rest and perform activity only as tolerated. Abstain from intercourse for the next 3-5 days. I have released her from work
for the next 36 hours.
SIGNATURE OF ED PHYSICIAN Frederick England
DD: 12-02-YYYY
DT: 12-03-YYYY
Frederick England, M.D.
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
RADIOLOGY REPORT
PATIENT NAME : MILLER, Stella PATIENT NUMBER: EDCase051
LOCATION : Emergency Room ED PHYSICIAN: Frederick England, M.D.
DATE OF SERVICE: 12-02-YYYY DATE OF BIRTH 07-29-YYYY
Radiology Report
EXAMS: 000070794 TRANSVAGINAL ENDOVAG 76830
ENDOVAGINAL ULTRASOUND:
Indication: Right-lower-quadrant pain; rule out ovarian cyst.
The uterus measures 10.5 x 5.2 x 5.8 cm. There is a 3.2 cm. anterior myoma. There is
a further submucosal myoma 1.5 cm. in diameter. The endometrium appears normal.
The right ovary measures 3.6 x 2.0 x 2.1 cm. The left ovary measures 2.8 x 2.4 x 2.9
cm. There is normal perfusion of both ovaries on Doppler ultrasound. No cyst, mass or
fluid collection is seen in the adnexal region.
IMPRESSION: Myomatous uterus. No ovarian abnormality is seen.
SIGNATURE OF RADIOLOGIST Philip Rogers
DD: 12-02-YYYY
DT: 12-04-YYYY
Philip Rogers, M.D., Radiologist
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
RADIOLOGY REPORT
PATIENT NAME : MILLER, Stella PATIENT NUMBER: EDCase051
LOCATION : Emergency Room ED PHYSICIAN: Frederick England, M.D.
DATE OF SERVICE: 12-02-YYYY DATE OF BIRTH 07-29-YYYY
Radiology Report
EXAMS: 000070843 ABD WWO CONTRAST 74170,
000070881 PELVIS W CONTRAST 72193
ABDOMEN AND PELVIC CT:
INDICATION: Right lower quadrant pain.
Contiguous axial 6.5 mm. sections were done from the diaphragms through the liver, spleen and kidneys, before and
during the intravenous administration of 125 ccs. of Optiray 240 without adverse effect. Oral contrast was also given.
Contiguous axial 6.5 mm. sections were done through the remainder of the abdomen and pelvis, after the abdominal scan
was performed.
ABDOMINAL FINDINGS: Examination of the abdomen demonstrates a grossly normal liver. I do not appreciate any focal
or diffuse abnormalities. The gallbladder appears normal without wall thickening, pericholecystic fluid, cholelithiasis or
other evidence of cholecystitis.
There is no dilatation of the intra or extra hepatic biliary ducts.
The spleen, pancreas and adrenal glands are grossly normal. There is grossly symmetric perfusion to the kidneys
bilaterally. The kidneys do not demonstrate any focal solid or cystic abnormalities. There is no hydronephrosis.
IMPRESSION: Normal abdomen.
PELVIS: Examination of the pelvis demonstrates normal bowel. I do not note any inflammatory changes in the region of
the appendix. The uterus appears grossly normal. There is evidence of fluid density in the region of the left ovary likely
representing a left ovarian cyst. I do not appreciate right ovarian mass. I do not note any free fluid within the pelvis. The
bladder is grossly normal.
IMPRESSION: probable left ovarian cyst without additional mass lesion or inflammatory change in the pelvis.
SIGNATURE OF RADIOLOGIST Denise Shanzer
DD: 12-03-YYYY
DT: 12-03-YYYY
Denise Shanzer, M.D. Radiologist
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
LABORATORY DATA
PATIENT NAME : MILLER, Stella PATIENT NUMBER: EDCase051
LOCATION : Emergency Room ED PHYSICIAN: Frederick England, M.D.
SPECIMEN COLLECTED: 12-02-YYYY-1025 SPECIMEN RECEIVED: Blood 12-02-YYYY-1028
Test Result Flag Reference
CBC
WBC 9.0 4.8-10.8 Th/mm3
RBC 4.20 4.20-5.40 Mil/mm3
HGB 12.5 12.5-16.0 g/dl
HCT 36.2 L 37.0-47.0 %
MCV 86.0 81.0-99.0 fl
MCH 29.7 27.0-31.0 pg
MCHC 34.5 32.0-36.0 g/dl
RDW 11.6 11.5-14.0 %
PLT 191 150-450 Th/mm3
DIFF, AUTO – 5
NE % 76.9 H 37.5-55.0%
LY % 12.9 L 25.0-33.3%
MO % 9.5 0.0-9.5%
EO % 0.2 0.0-6.7%
BA % 0.5 0.0-1.0%
NE # 6.9 H 1.5-6.6 Th/mm3
LY # 1.2 L 1.5-3.5 Th/mm3
MO # 0.9 0.0-1.0 Th/mm3
EO # 0.0 0.0-1.7 Th/mm3
BA # 0.0 0.0-0.1 Th/mm3
SLIDE REVIEWED NO
** END OF REPORT **
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
LABORATORY DATA
PATIENT NAME : MILLER, Stella PATIENT NUMBER: EDCase051
LOCATION : Emergency Room ED PHYSICIAN: Frederick England, M.D.
SPECIMEN COLLECTED: 12-02-YYYY-0959 SPECIMEN RECEIVED: Urine 12-02-YYYY-1027
Test Result Flag Reference
URINALYSIS
UA WITH MICRO
COLOR Pending
APPEARANCE Pending
SP GRAVITY Pending
GLUCOSE NORMAL NORMAL mg/dl
BILIRUBIN NEGATIVE NEG
KETONE NEGATIVE NEG mg/dl
BLOOD NEGATIVE NEG
PH 6.0 4.5-8.0
PROTEIN NEGATIVE NEG mg/dl
UROBILINOGEN NORMAL NORMAL-1.0 mg/dl
NITRITES NEGATIVE NEG
LEUKOCYTES NEGATIVE NEG
** END OF REPORT **
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
LABORATORY DATA
PATIENT NAME: MILLER, Stella PATIENT NUMBER: EDCase051
LOCATION : Emergency Room ED PHYSICIAN: Frederick England, M.D.
SPECIMEN COLLECTED: 12-02-YYYY-1025 SPECIMEN RECEIVED: 12-02-YYYY-1028
Test Result Flag Reference
HCG QUAL SERUM NEGATIVE NEGATIVE
** END OF REPORT **
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
LABORATORY DATA
PATIENT NAME : MILLER, Stella PATIENT NUMBER: EDCase051
LOCATION : Emergency Room ED PHYSICIAN: Frederick England, M.D.
SPECIMEN COLLECTED: 12-02-YYYY-1025 SPECIMEN RECEIVED: 12-02-YYYY-1028
Test Result Flag Reference
AMYLASE 63 25-125 U/L
** END OF REPORT **
Global Care Medical Center
100 Main St, Alfred NY 14802
(607) 555-1234
LABORATORY DATA
PATIENT NAME : MILLER, Stella PATIENT NUMBER: EDCase051
LOCATION : Emergency Room ED PHYSICIAN: Frederick England, M.D.
SPECIMEN COLLECTED: 12-02-YYYY-1134 SPECIMEN RECEIVED: 12-02-YYYY-1134
Test Result Flag Reference
GENPROBE CHL/GC
DIRECT TEST CHL NEGATIVE
DIRECT TEST GC NEGATIVE
Test performed at Jones Hospital,
Wellsville, NY
** END OF REPORT **
I need the ICD-10-CM Code and CPT code for this case study?
