Oct 28th, 2013 - samcodie84 1
LOCATION: Hospital Emergency Department
PHYSICIAN: Paul Sutton, MD
CHIEF COMPLAINT: Level 3 trauma
SUBJECTIVE: a 44-year-old female was treating a sick calf when a cow attacked and stomped her. She presents to the emergency room via ambulance complaining of an open ankle dislocation. She is also complaining of some abrasions on her chin and under her left leg. She specifically denies loss of consciousness or headache. No neck, back, chest, abdomen, or pelvic pain. She is quite stoic.
PAST MEDICAL HISTORY: Remarkable for some hypertension, depression, and migraine.
II. Question Xanax
FAMILY HISTORY: Deemed noncontributory
SOCIAL HISTORY: She is married,, I believe is a nonsmoker, and is a laborer.
REVIEW OF SYSTEMS: As above. She says her foot is cold.
PHYSICAL EXAMINATION: Preliminary survey is benign. Secondary survey: Alert and oriented X 3. Immobilized in a C-collar and long spine board. Head is normocephallic. There is no hemotympanum. Pupils are equal. There is an abrasion under her chin. Trachea is midline. She does have a C-collar in place. Air entry is equal. Lungs are clear. Chest wall is nontender. Abdomen is soft. Pelvis is stable. Long bones are remarkable for an obvious open dislocation of the right ankle. The toes are all dusky, she has a strong posterior tibial pulse, and the nurse thinks she felt a faint dorsalis pedis. She has an abrasion under her left leg.
HOSPITAL COURSE: We did give her a tetanus shot and 1 g of Ancef. I immediately gave her some parenteral Fentanyl and Versed, and we were able to reduce the dislocation without difficulty. Postreduction film looks surprisingly good. There is perhaps a subtle fracture noted only on the lateral projection. C-Spine shows some degenerative change, is of poor quality, but is negative; upon re-examination she is not tender in that area. However, it was done because she had such a severe distracting injury and given the mechanism. Chest x-ray and left femur look fine.
ASSESSMENT: Level 3 trauma with an open right ankle dislocation, multiple abrasions.
PLAN: Plan to call Dr. Almaz, who graciously agreed to assume care. The patient is kept n.p.o.
Identify the correct diagnosis (ICD-9-CM) code(s) for the hospital emergency department visit for the patient: ICD-9-CM: __________, ICD-9-CM: __________, ICD-9-CM: __________, E__________