PREOPERATIVE DIAGNOSIS: Morbid obesity with significant comorbidities. POSTOPERATIVE DIAGNOSIS: Morbid obesity with significant comorbidities and BMI of 45.0. PROCEDURE: Laparoscopic adjustable gastric band with an AP standard band. ANESTHESIA: General via endotracheal tube. ESTIMATED BLOOD LOSS: Minimal. SPECIMEN: None. COMPLICATIONS: None. INDICATION: Patient is a very pleasant 33 year-old fema...
In ICD-10
Sep 9th, 2015
CHIEF COMPLAINT: Chest pain. HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old white male who presents with a chief complaint of “chest pain”. The patient has coronary artery disease of the native arteries. The patient suffered an MI of the left anterior descending artery one week ago and was released two days prior to presentation at this ...
In CMS
Aug 6th, 2015
Description: Skin biopsy was performed on the right ankle and right thigh on two suspicious skin lesions. The complications, instructions as to how the procedure will be performed, and postoperative instructions were given to the patient. The patient consented for skin biopsies. The complications, instructions on the procedure, and postop instructions were given to the ...
May 14th, 2015
Subjective: I am asked to see the patient today for ongoing issues around her diabetic control. We have been fairly aggressively, downwardly adjusting her insulins, both the Lantus insulin, which we had been giving at night, as well as her sliding scale Humalog insulin prior to meals. Despite frequent decreases in her insulin regimen, she ...
In ICD-10
Apr 6th, 2015
HISTORY OF PRESENT ILLNESS: This is a follow up for this 69-year-old gentleman with stage IV chronic kidney disease. His creatinine has ranged between 4 and 4.5 over the past six months (since I have been following him). I have been trying to get him educated about end-stage kidney disease and we have been unsuccessful in getting ...