Might be a bit long but I get an ER visit code as opposed to Critical Care despite what's listed. What would you recommend. Bear with me please. THANK YOU SO MUCH!!!
CHIEF COMPLAINT: found down
PERTINENT TRAUMA CRITERIA: Patient was deemed to meeet trauma activation criteria and was activated as a code trauma. The patient was brought to Hospital as regional trauma center and I was summoned to see the patient as the trauma surgeon on duty and was there to per form the Emergency Assessment Trauma Eval and Critical Care Management eval on this patient on an emergency basis as mandated by state and federal law. The Amer College of Surgeons Advanced Trauma Life Support Protocaol was followed in the Eval, Trauma Management, and Critical Care of this patient
HISTORY OF PRESENT ILLNESS: The patient is 65 years old and was found down by family. The paramedics on arrival stated that they noted no evidence of trauma but he had altered mental status, but was intact. He was, therefore activated as a code trauma. He arrived by ambulance at XX:XX. I was summoned to see the pt as the trauma surgeon on duty to perform the emergency assessment and trauma eval and critical care management of this pt. In accordance w/the american College of Surgeons advanced trauma life support protocol. I initiated my assessment w/ the primary survey
PRIMARY SURVEY: A: Airway - open and patent B: Breathing - Spontaneously w/o paradoxical check wall motion C: Circulation - warm palpable pulses and brisk capillary refill in all four extremities D: Deformity and Disability - no evidence of a bone or gross body torso deformity E: Exposure: clothes removed no signs of open hemorrhagic lacerations
GENERAL ASSESSMENT: Pt was awake, alert and oriented. He is acutely intoxicated and had a Glasgow Coma Score of initially 13, which increased to 15 over time of initial consultation. I was unable to get medical info. Past Medical, Surgical and Allergies unknown
SOCIAL HISTORY: Alcohol Use; positive for recent alcohol intoxication
FAMILY HISTORY: Unknown
TETANUS TOXOID STATUS unknown, REVIEW OF SYSTEMS Denied any pain at this time,
PHYSICAL EXAM AND SECONDARY SURVEY
GENERAL Well developed well nourished, VITAL SIGNS Pulse, respiration, Temp normal, HEAD: without signs of lacerations abrasions or contusion, normal cranial and atraumatic. EYES: pupils equal, round, reactive, good visual acuity, sees fingers clearly EARS: canals clear no signs of hemotympanum bilaterally no tympanic membrrane injury, not external lacerations, abrasion or contusions. POSTERIOR CERVICAL SPINE: posterior cervical spine was palpated w/o signs of ternderness, no bony step-off or crepitus. ANTERIOR MID FACE: w/o deforminty no laceratons, abrasions, or contusions. NOSE w/o signs of septal deviation, no hematoma and rhinorrhea no lacerations or abrasions ORAL CAVITY: w/o signs of lacerations, abrasions or contusions. MANDIBLE: non tender w/o bony deformity ANTERIOR NECK: w/o crepitance. Trachea midline, no stridor sounds, no distention of neck veins no lacerations abrasions contusions. CHEST clear good breath sounds, no wheezes rales rhonchi, no lacerations abrasions or contusions to chest wall HEART: regular rate and rhythm ABDOMEN: non tender no rebound, guarding, peritoneal signs. PELVIS: Stable upon rocking no lacerations, abrasions or contusions. EXTREMITIES: good palpable pulses and brisk capillary refill, moved all fingers and toes w/o limitation, good sensation, no signs of L, A, C. BACK: no pain or discomfort. w/o palpable bony deformity no signs of L, A, C. NEUROLOGIC: cranial nerves were evaluated and were intact
LABORATORY STUDIES: HEMATOLOGY, wbc 10.0 Hemo 15.0 platelets 148, sodium 144 potassium 3.9 chloride 105 Blood Alcohol 556mg, Troponins are negitive
RADIOLOGIC STUDIES Chest X ray Negative for thoracic trauma, Pelvis Xray Neg for fracture, CT OF HEAD Neg for ICH, CT of Neck NEG for fracture
ANALYSIS AND PLAN: Pt heavily intoxicated with no external evidence of injury in our workup, concerning only for his alcohol intoxification. He had no acute signs of trauma. Once he was more awake, his cervical spine was able to be cleared using radiographic workup criteria. However, given his extreme intoxication he was recommended to be transferred to the Emergency Room for further eval of his altered mental status and potential treatment for his acute alcohol intoxication
Total in Trauma and Critical Care time is 55 Minutes
Now the question... Critical Care 99291? Or ER Visit....?? THANKS AGAIN !
CHIEF COMPLAINT: found down
PERTINENT TRAUMA CRITERIA: Patient was deemed to meeet trauma activation criteria and was activated as a code trauma. The patient was brought to Hospital as regional trauma center and I was summoned to see the patient as the trauma surgeon on duty and was there to per form the Emergency Assessment Trauma Eval and Critical Care Management eval on this patient on an emergency basis as mandated by state and federal law. The Amer College of Surgeons Advanced Trauma Life Support Protocaol was followed in the Eval, Trauma Management, and Critical Care of this patient
HISTORY OF PRESENT ILLNESS: The patient is 65 years old and was found down by family. The paramedics on arrival stated that they noted no evidence of trauma but he had altered mental status, but was intact. He was, therefore activated as a code trauma. He arrived by ambulance at XX:XX. I was summoned to see the pt as the trauma surgeon on duty to perform the emergency assessment and trauma eval and critical care management of this pt. In accordance w/the american College of Surgeons advanced trauma life support protocol. I initiated my assessment w/ the primary survey
PRIMARY SURVEY: A: Airway - open and patent B: Breathing - Spontaneously w/o paradoxical check wall motion C: Circulation - warm palpable pulses and brisk capillary refill in all four extremities D: Deformity and Disability - no evidence of a bone or gross body torso deformity E: Exposure: clothes removed no signs of open hemorrhagic lacerations
GENERAL ASSESSMENT: Pt was awake, alert and oriented. He is acutely intoxicated and had a Glasgow Coma Score of initially 13, which increased to 15 over time of initial consultation. I was unable to get medical info. Past Medical, Surgical and Allergies unknown
SOCIAL HISTORY: Alcohol Use; positive for recent alcohol intoxication
FAMILY HISTORY: Unknown
TETANUS TOXOID STATUS unknown, REVIEW OF SYSTEMS Denied any pain at this time,
PHYSICAL EXAM AND SECONDARY SURVEY
GENERAL Well developed well nourished, VITAL SIGNS Pulse, respiration, Temp normal, HEAD: without signs of lacerations abrasions or contusion, normal cranial and atraumatic. EYES: pupils equal, round, reactive, good visual acuity, sees fingers clearly EARS: canals clear no signs of hemotympanum bilaterally no tympanic membrrane injury, not external lacerations, abrasion or contusions. POSTERIOR CERVICAL SPINE: posterior cervical spine was palpated w/o signs of ternderness, no bony step-off or crepitus. ANTERIOR MID FACE: w/o deforminty no laceratons, abrasions, or contusions. NOSE w/o signs of septal deviation, no hematoma and rhinorrhea no lacerations or abrasions ORAL CAVITY: w/o signs of lacerations, abrasions or contusions. MANDIBLE: non tender w/o bony deformity ANTERIOR NECK: w/o crepitance. Trachea midline, no stridor sounds, no distention of neck veins no lacerations abrasions contusions. CHEST clear good breath sounds, no wheezes rales rhonchi, no lacerations abrasions or contusions to chest wall HEART: regular rate and rhythm ABDOMEN: non tender no rebound, guarding, peritoneal signs. PELVIS: Stable upon rocking no lacerations, abrasions or contusions. EXTREMITIES: good palpable pulses and brisk capillary refill, moved all fingers and toes w/o limitation, good sensation, no signs of L, A, C. BACK: no pain or discomfort. w/o palpable bony deformity no signs of L, A, C. NEUROLOGIC: cranial nerves were evaluated and were intact
LABORATORY STUDIES: HEMATOLOGY, wbc 10.0 Hemo 15.0 platelets 148, sodium 144 potassium 3.9 chloride 105 Blood Alcohol 556mg, Troponins are negitive
RADIOLOGIC STUDIES Chest X ray Negative for thoracic trauma, Pelvis Xray Neg for fracture, CT OF HEAD Neg for ICH, CT of Neck NEG for fracture
ANALYSIS AND PLAN: Pt heavily intoxicated with no external evidence of injury in our workup, concerning only for his alcohol intoxification. He had no acute signs of trauma. Once he was more awake, his cervical spine was able to be cleared using radiographic workup criteria. However, given his extreme intoxication he was recommended to be transferred to the Emergency Room for further eval of his altered mental status and potential treatment for his acute alcohol intoxication
Total in Trauma and Critical Care time is 55 Minutes
Now the question... Critical Care 99291? Or ER Visit....?? THANKS AGAIN !
