ED Coding and Reimbursement Alert

History of Present Illness (HPI):

The patient is a 51-year-old female who fell down six stairs just prior to arrival and injured her right upper extremity, her left knee, and her left ankle. She denies other injuries, symptoms, or complaints. She denies any head trauma, neck, or back injury. She is transported to the emergency room via ambulance with paramedics in attendance. Radio control was established en route. She arrives immobilized on a long spine board.

Review of Systems (ROS):

Negative for chronic illness or conditions other than some osteoarthritis and hypertension.

Patient, Family, Social History (PFSH):

No alcohol or tobacco abuse.

Exam:

Vital Signs: Blood pressure: 152/85; pulse: 63; respirations: 20.
Temperature: 97.0.
General: Moderate discomfort secondary to right-elbow area pain. Alert and oriented times three. Initially mobilized on a long spine board but ultimately mobile after evaluation. Conversant and appropriate. Good color.
Neurologic: Intact and negative without focality or asymmetry.
HEENT (Head, Eyes, Ears, Nose, and Throat): Pupils are equal, round and reactive to light. Extraocular movements within normal limits. Visual acuity intact. Discs and tympanic membranes are negative. Facial/oral negative. No tenderness or swelling.
Neck: No tenderness or spasm. Spontaneous, full range of motion.
Chest: Clear with bilateral breath sounds. Regular sinus rhythm and no rubs. No thorax tenderness. Normal air exchange and no respiratory compromise.
Abdomen: Soft with active bowel sounds. Nondistended and nontender. No guarding or rebound.
Back: No costovertebral angle, flank or spine tenderness. Good truncal range of motion.
Pelvis/Hips: Stable and nontender. Full range of motion bilaterally.
Extremeties: Tenderness and swelling about the right elbow with decreased range of motion secondary to pain. Distal neurovascular appears intact although the patients motions are somewhat limited secondary to her pain at her elbow, but I do not believe there is any overt, neurologic deficit present. Although the patient is hesitant to fully flex and extend her wrist secondary to pain, I think the motion and strength are there. No skin breaks, ecchymoses or deformities. Remainder of distal neurovascular is intact with good fingertip color, warmth, and sensation and good distal pulses. The remainder of the right upper extremity is otherwise negative. Left upper extremity is normal and unremarkable. Right lower extremity is normal and unremarkable. Left lower extremity exhibits some mild tenderness over the anterior knee and over the anterior lateral ankle, but there is good range of motion of both with no swelling or deformity, and distal neurovascular is intact.

Diagnostic Test Results:

X-rays reveal a posterior elbow dislocation with a radial head fracture.

Procedure:

Right elbow dislocation is reduced with traction without anesthesia without difficulty. Post reduction x-rays reveal the correction of the dislocation. The radial fracture remains. The patient is observed in the emergency department over the course of several hours, and distal neurovascular on the right upper extremity appears to remain intact. The patient is still hesitant to fully move her wrist and hand, but I think her movements are intact. They are just limited by her apprehension and pain from the injury at her elbow level.

Assessment:

1) Right elbow posterior dislocation.
2) Right radial head fracture.
3) Left knee contusion.
4) Left ankle contusion.

Plan of Care:

1) A right upper extremity plaster splint.
2) Soft splints to left lower extremity, knee, and ankle.
3) Ice and elevation to all injuries.
4) Percocet as needed for pain.
5) Follow up w/ orthopedic MD in one day.
6) Return to the emergency room as needed