Author: Anonymous

Emergency Department – Patient 7Use the chart documentation below for questions 119-121.___________________________________________________________________________________________________________________________History and Physical ExamDATE: 7/16CHIEF COMPLAINT: Shortness of breath and dyspneaHISTORY (PROBLEM FOCUSED):HISTORY OF PRESENT ILLNESS:This 81-year-old presents today with complaints of shortness of breath and dyspnea. No cough or sputum production. No pleuritic chest pain or hemoptysis. She has vague complaints of some pain. She has been taking acetaminophen without much relief. Patient is accompanied by her daughter.PAST MEDICAL HISTORY:       COPD    Chronic hypoxic respiratory failure    History of lung cancerFAMILY HISTORY: Reveals that her mother has a history of migraines and depression.SOCIAL HISTORY: She does not smoke or use alcohol.MEDICATION: Albuterol inhaler 180mcg (2 puffs) inhaled orally every 4–6 hours; not to exceed 12 inhalations/24 hours; oxygen 2 liters.ALLERGIES: NonePHYSICAL EXAMINATION (PROBLEM FOCUSED):MDM: LowVITAL SIGNS: Blood pressure 136/82, pulse 94, respiratory rate 18, weight 100.5 pounds, oxygen saturation 97% on two liters, continuousGENERAL: Chronically ill-appearing, thin, elderly, white femaleHEENT: Pupils are minimally reactive. Bilateral arcus senilis. Oral cavity is grossly normal.NECK: No lymphadenopathyLUNGS: Decreased breath sounds. Prolonged respiratory phase. Scattered rales are heard at the lung bases.HEART: Distant heart sounds. Regular rhythm.ABDOMEN: Soft. Liver and spleen not enlarged.EXTREMITIES: Trace edema. No cyanosis or clubbing.RADIOLOGY: Chest x-ray ordered and reviewed without benefit of the radiologist’s report. Heart size is at the upper limits of normal. There is scarring and retraction in the right lower lung field. There are emphysematous changes noted. Previous pulmonary function studies are reviewed. LABORATORY: CBC ordered and all values within normal limits.ASSESSMENT:1. COPD2. Pain, multifactorial3. History of lung cancerFOLLOW-UP: Hydrocodone every 6–8 hours for pain. Follow-up with primary care provider in two weeks. Maintain current O2 levels at 2 liters.

This Mock Exam has a time limit of 4 hours (240 minutes).This Mock Exam consists of 124 multiple choice questions.        #1-100 are general questions that cover Domains 1-5.        #101-124 are medical scenario questions, which are divided into 8 different patient scenarios.Some of the medical scenario questions will require multiple answer selections for the secondary diagnoses and procedures.Questions #1-100 are worth 1 point each; The medical scenario questions are worth 2 points each for the first-listed/principal diagnosis code questions and 10 points for the secondary diagnosis(es) and procedure(s).Partial credit is awarded for the secondary diagnoses and procedure codes, as applicable.This Mock Exam will save and submit automatically when the time expires.The timer will continue to run if you leave the Mock Exam, so you should plan to take this Mock Exam in one sitting.This Mock Exam is due on July 27, 2026 11:59:00 PM EDT.The use of a secondary device (laptops, smartphones, smartwatches, tablets, etc.) is not allowed and considered a form of academic dishonesty and the consequences of doing so may result in a zero for a first offense and WF for repeated offenses. Honorlock flags students who are caught using a secondary device. Also prohibited are the following: notes, texts, online materials or other such unauthorized materials; for example, connecting with classmates by phone, email, Snapchat, GroupMe etc. while taking quizzes and tests.You are PERMITTED to use your ICD-10-CM, CPT, and ICD-10-PCS 2026 Coding Manuals. These are the ONLY resources that may be used. You may use blank scratch paper to write down code possibilities. 

A PACS system is going to house what type of electronic health records?

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A 27-year-old female presents to the emergency department complaining of shortness of breath and wheezing. The patient is given epinephrine and nebulizer treatments. The shortness of breath and wheezing are unrelieved following treatment. What diagnosis might the coding professional suspect?

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