Audit Report 1.4 Emergency Department Services
LOCATION: Hospital Emergency Department
PATIENT: Fran Green
PHYSICIAN: Paul Sutton, MD
CHIEF COMPLAINT: Level 3 trauma
Subjective: A 44-year-old female was treating a sickcalf when a cow attacked her and stomped her. She presents to theemergency room via ambulance complaining of an open ankledislocation. She also is complaining of some abrasions on her chinand under her left leg. She specifically denies loss ofconsciousness or headache. No neck, back. chest, abdomen, or pelvicpain. She is quite stoic.
PAST MEDICAL HISTORY: Remarkable for somehypertension, depression, and migraine.
MEDICATIONS
1. Premarin
2 Question Xanax
ALLERGIES: None
FAMILY HISTORY: Deemed non contributory
Social HISTORY: She is married, I believe a nonsmoker, and is a laborer.
REVIEW OF SYSTEMS: As above. She says her foot iscold.
Physical EXAMINATION: Preliminary survey is benign.Secondary survey: Alert and Oriented x3. Immobilized in a C-collarand long spine board. Head is normocephalic. There is nohemotympanum. Pupils are equal. There is an abrasion under her chinTrachea is midline. She does have a C collar in place. Air entry isequal. Lungs are clear. Chest wall is nontender. Abdomen is soft.Pelvis is stable. Long bones are remarkable for an obvious opendislocation of the right ankle. The toes are all dusky. she has astrong posterior tibial pulse, and the nurse thinks she felt afaint dorsalis pedis. She has an abrasion under her left leg.
HOSPITAL COURSE: We did give her a tetanus shot and 1g of Ancef. I immediately gave her some parenteral Fentanyl andVersed, and we were able to reduce the dislocation withoutdifficulty. Postreduction film locks surprisingly good. There isperhaps a subtle fracture noted only on the lateral projection.C-spine shows some degenerative change, is of poor quality, but isnegative, and upon re-examination she is not tender in that area.However, it was done because she had such a severe distractinginjury and given the mechanism. Chest x-ray and left femur lookfine.
ASSESSMENT: Level 3 trauma with an open right ankledislocation, multiple abrasions
PLAN: Plan to call Dr. Almaz, who graciously agreed toassume care. The patient is kept n.p.o.
One or more of the following codes is/are reportedincorrectly missing for this case. Indicate the incorrect ormissing code on codes.
SERVICE CODE(S): Evaluation and Management, 99282
ICD-10-CM DX CODE(S): Ankle dislocation, S93.04XA,Open wa right ankle, S91.001A Abrasion of head, S00.81XA, Abrasion,left leg. S80.812
(INCORRECT/MISSING CODES):
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