QUESTION: This is an authentic coding case for an Outpatient Clinic case for Injury and PoisoningPle

QUESTION: This is an authentic coding case for an Outpatient Clinic case for Injury and PoisoningPlease review the documentation of the patient encounter and code the case. You may use ICD-10-CM including External Cause Codes, CPT, and HCPCS codes. (I believe there is 15 codes total) Department of Orthopedics Hand and Upper Extremity Surgery CHIEF COMPLAINT:  Patient presents with Wrist Injury right HISTORY OF PRESENT ILLNESS: a 70 y.o. right hand dominant female who presents today for a right distal radius fracture 5 days sip fall (DOI: ). She was taking care of nubian milking goats for her children when she got caught in a leash while a goat was stepping on her foot which caused her to fall backwards bracing herself on on her outstretched right hand. She did not hit her head and denies LOC, CP, or dizziness prior to falling. She was seen in the ED where she was found to have a distal radius fracture and was subsequently placed in a splint. Although her pain is improved in the splint she has continued to have pain over the past 5 days. The pain is a dull burning 5/10 pain in her right wrist that radiates up to her elbow. If she tries to lift her arm the pain is sharp and increases to an 8/10. She volunteers at her church catering events including a weekly supper on Wednesdays for 150 people, she would like to be able to have optimal function of her wrist and hand to be able to continue cooking. She denies N/T. She denies pain in the right elbow and shoulder and denies any other injuries. PAST MEDICAL HISTORY: Late Effects of CVA (Cerebrovascular Accident) dysphasia/aphasiaHTN (hypertension), benign Dyslipidemia Pulmonary hypertensionAdjustment disorder with mixed anxiety and depressed moodGAD (generalized anxiety disorder) S/P colonoscopy with polypectomyTubular Adenomatous poly of colon next colonoscopyMigraine equivalent syndrome CPR elevated  Diverticular disease of colon  PFO ( Patient foramen Ovale) S/P helix occlusion implantGERD (gastroesophageal reflux disease) HypothyroidismAscending Aortic Aneurysm yearly CT scan f/u nextAnemia, iron deficiency Accidental fall from ladderCough URI (upper respiratory infection)  Shoulder impingement Allergy to environmental factors  Anxiety Depression Unspecified cerebral artery occlusion with cerebral infarction  Allergies:  Zocor (Simvastatin) Muscle aches  Ace Inhibitors severe cough  Caffeine Elevated BP  Diovan (Valsartan) Cough  Minocycline Elevated LFT’s Social History:MarriedFormer smoker 3.00 packs/ day for 10 years REVIEW OF SYSTEMS:A 12 point review of systems questionnaire was completed by the patient during this visit. ,reviewed, signed, and dated this form and made it a part of the patient’s permanent record. The pertinent positives are noted in the HPI PHYSICAL EXAMINATION: Vital Signs: There were no vitals taken for this visit. The patient is a well-nourished, well developed female. The patient presents as alert and oriented x 3. The patient is pleasant and in no distress. Right Upper Extremity: Vascular: Hand warm and well perfused with a 2+ radial pulse. Sensory: Sensation intact to light touch. Skin: Skin intact with no lacerations or lesions. Inspection/Palpation – Splint in place, inspection/palpation of elbow deferred. Fingers swollen. ROM – Splint in place, ROM of elbow and shoulder deferred. Fingers with decreased ROM secondary to swelling. Stability – Splint in place, deferred. Strength – Splint in place, strength deferred.  Left Upper Extremity: Vascular: Hand warm and well perfused with a 2+ radial pulse. Sensory: Sensation intact to light touch. Skin: Skin intact with no lacerations or lesions.Inspection/Palpation – No bony deformities or malalignment. No TTP anywhere about the upper extremity. ROM – Full ROM of the shoulder, elbow, forearm, wrist, and fingers without pain, crepitation, or contracture. Stability – No evidence of dislocation, subluxation, or laxity through FROM of the shoulder, elbow, wrist, fingers. Strength – 5/5 strength of the rotator cuff, elbow flexors/extensors, wrist flexors/extensors, EPL, FPL, APB, interossei, FDP/S, and EDC to each finger. No musce wasting.  RADIOLOGY: Radiographs taken previously include AP, lateral and oblique of the elbow and wrist. These images were reviewed by me, and demonstrate no signs of fracture at the right elbow, the wrist films demonstrate an impaction fracture of the right distal radius.  ASSESSMENT: Right distal radius fracture PLAN: was seen today for wrist injury.  Diagnosis and associated orders for this visit:Right wrist pain XR Wrist; Future Occupational/ Hand/ Physical Therapy (Shands); Future Ortho Surgery Request – Hand  Other closed fractures of distal end of radius (alone) Occupational/ Hand/ Physical Therapy (Shands); Future Ortho Surgery Request – Hand  Plan for ORIF of right distal radius fracture to be scheduled Thursday, This procedure has been fully reviewed with the patient including risks and complications. The patient agrees and written informed consent has been obtained. advised to keep arm elevated and to work on ROM of fingers. Patient Discharge Instructions Hand/ Upper Extremity Surgery DO NOT bear weight on your right handDrink plenty of fluids. Clear liquids initially, progressing slowly to soft diet as tolerated. It is better to start with liquids such as ginger ale or apple juice, then soup and crackers and gradually solid foodsResume normal activities slowly. Children should be encouraged to rest, but may resume activities according to Doctor’s instructionsKeep operative areas clean and dry. i.e. dressing, splint, castYou may notice small amounts of “bloody” drainage on your dressing for the first 2-3 days, this is normal. Observe the operative area for signs of excessive bleeding; e.g., slow general oozing that saturates the dressing completely or frank bright, red bleeding. In either case, apply pressure to the area, elevate it if possible and contact your physician immediately!Keep operative site elevated above heart level for the next 2-3 days, as appropriate.Avoid stress to suture line (such as pulling, pushing, etc.). No strenuous activity or heavy lifting.If your fingers are not included in the dressing, move them through full motion to prevent stiffness and decrease swelling as tolerated.• If you are placed in a bulky dressing without a splint, protect extremity until seen by physicianUse sling when up walking for the next 2-3 days; positioned with hand above elbowDO NOT wet your cast. If you get your cast wet, you should contact your doctor. DO NOT attempt to dry the cast using heaters or hair dryer. – Lightly apply cream to dry skin of fingers as needed. – If you have an arm cast, wear a sling during the DAY and remove the sling only when you ELEVATE the arm. – DO NOT work out (exercise), go to the gym, or take part in athletic activities. – Activities of children who have casts should be supervised by their parents or a responsible adult• If you received a regional anesthesia: Sensation of your extremity should return slowly. When a dull tingling feeling returns, take your prescribed pain medication. Notify your physician if: – Notice excessive swelling – Pain or bruising under your arm. Protect your arm especially during this time frame.Notify your physician immediately if any of the following symptoms occurs: – If your casts gets wet – If you observe changes in the color, temperature or sensation of the extremity – Increased pain unrelieved by pain medicationPreoperative Diagnosis: Right distal radius fracture.Postoperative Diagnosis: Right distal radius fracture.Anesthesia: Regional with sedation. Procedure:  Open reduction, internal fixation, right distal radius fracture.Implants: Synthes distal radius plate and screws.  Description of Procedure: The patient was identified and marked preoperatively. A regional block was provided by Anesthesia. The patient was brought into the Room, placed supine upon the Operating Room table. Tourniquet was applied to the right upper extremity. Right upper extremity was prepped and draped in the usual sterile fashion. Preoperative antibiotics were administered and a time-out was performed. The extremity was exsanguinated with a bandage and tourniquet inflated to 250 mmHg. A longitudinal incision was made overlying the FCR tendon at the distal forearm. Dissection was taken down through the subcutaneous tissues. The FCR tendon sheath was incised and the tendon was retracted. The floor of the sheath was incised. Dissection was carried down to the pronator quadratus which was elevated off the distal radius exposing the fracture site. The brachioradialis was released off of the distal radius. The fracture site was developed with a curette and a Freer and provisional reduction was able to be performed. A Synthes distal radius plate was selected and secured to the shaft in an oblong hole with a cortical screw. Next, the fracture was reduced and pinned through the distal holes with multiple K-wires. We then filled the distal hole with a cortical screw , filled the remainder of the distal row with locking screws and refilled the initial hole with a locking screw distally. The remainder of the proximal holes were filled with cortical screws. Final fluoro spots were taken. The wound was irrigated copiously with saline. The subcutaneous tissues were closed with 4-0 Vicryl and the skin was closed with staples. Adaptic, 4x4s and a volar splint were fashioned. The tourniquet was let down, fingers pinked up. The patient was awoken and transferred to the Recovery Room in stable condition.  ADDENDUM:  AP and lateral views were taken at the end of the case. Examination of these demonstrated interval improvement of the alignment in the distal radius fracture stabilized by distal radius plates and a combination of cortical and locking screws. The hardware appears to be extraarticular on the lateral view. Health Science Science Nursing HCMT 2025C Share QuestionEmailCopy link Comments (0)

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