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PT here for f/up of ORIF RIGHT subtroch hip fracture treated in outside the USA 3/2/10. She fell while disembarking from a van onto a cobblestone surface. While hospitalized she sustained a sacral decubitus ulcer. She recently returned to her home here on 3/15/10. She is here for f/up care.
She has little pain. She is not taking pain medication. Ambulation with walker is difficult and patient requests wheelchair.
EXAM
Marked sacral erythema. Large decubitus. Foul smelling. Dressing applied in outsied the USA
Hip wounds and knee wounds well healed without evidence of infection.
XRAYS
Subtroch RIGHT hip fx with reverse obliquity txed with locked IM nail. Fx is somewhat displaced/distracted?
AP
S/P ORIF RIGHT subtroch fx; treatment Outside the USA.
Sacral decubitus.
TTWB with walker
Physical therapy for transfers, etc.
Gen surgery to see today for decubitus management.
F/up one month with new xray of hip.
Discussed the possiblity of non-union.
Should we use the Aftercare code for her first vist to the dr. in the US or the acute fx code.
She has little pain. She is not taking pain medication. Ambulation with walker is difficult and patient requests wheelchair.
EXAM
Marked sacral erythema. Large decubitus. Foul smelling. Dressing applied in outsied the USA
Hip wounds and knee wounds well healed without evidence of infection.
XRAYS
Subtroch RIGHT hip fx with reverse obliquity txed with locked IM nail. Fx is somewhat displaced/distracted?
AP
S/P ORIF RIGHT subtroch fx; treatment Outside the USA.
Sacral decubitus.
TTWB with walker
Physical therapy for transfers, etc.
Gen surgery to see today for decubitus management.
F/up one month with new xray of hip.
Discussed the possiblity of non-union.
Should we use the Aftercare code for her first vist to the dr. in the US or the acute fx code.
