trose45116
Expert
I am only getting a level 2 out of this??? what are everyone's thought of this?? am I missing something to make it a level 3???
I only see 3 elements on the hpi I got expanded HISTORY
complete ros I got a DETAILED EXAM
complete pfsh I got a LOW MDM
Left wrist pain.
HPI:
Appointment type:
New patient - Consult requested by Nextcare Urgent Care
patient is a 55-year-old male who comes in with chief complaint of left wrist pain. He did have a fall onto outstretched arm. Date of injury 1/15/2016. He did have radiographs. This was noted as being fractured. He comes in today for evaluation. He has pain about the wrist. He denies neck pain. He denies numbness or paresthesias in the right upper extremity. He denies any other complaints. Rest makes his pain better. Activity makes his pain worse
.
ROS:
General/Constitutional:
Denies Thirst - Excessive. Denies Chills.
ENT:
Denies Ear Discharge. Denies Bleeding Gums.
Respiratory:
Denies Coughing. Denies Hemoptysis.
Cardiovascular:
Denies Tachycardia. Denies Circulation Problems.
Gastrointestinal:
Denies Bowel Changes. Denies Constipation.
Genitourinary:
Denies Blood in Urine. Denies Frequent Urination.
Musculoskeletal:
Denies Arthritis, denies. Denies Back Pain, denies.
Skin:
Denies Dry/Sensitive Skin. Denies Rash.
Neurologic:
Denies Coordination Problems. Denies Memory loss. Denies Seizures.
Psychiatric:
Denies Anxiety. Denies Depression.
Surgical History: vasectomy .
Family History:
cancer.
Social History:
tobacco- yes
alcohol- yes
divorced.
Medications: None
Allergies: N.K.D.A.
Objective:
Vitals: Wt 175 lbs, BMI 24.40 Index, Ht 5 ft 11 in.
Physical Examination:
Examination of the right hand and wrist reveals no evidence of skin abnormality. He does have swelling about the distal radius. His pain with palpation about the radius and ulna to palpation. Full digital range of motion. No pain with palpation about the remainder the hand. He does have some pain with palpation around the scapholunate articulation. Full elbow and shoulder range of motion. Normal motor sensation pulses skin examination distally.
Assessment:
Assessment:
1. Other extraarticular fracture of lower end of left radius, initial encounter for closed fracture - S52.552A (Primary)
2. Wrist pain, left - M25.532
Plan:
1. Other extraarticular fracture of lower end of left radius, initial encounter for closed fracture
Notes: I had a long discussion with the patient. I did describe doing an MRI of the wrist to evaluate the scapholunate ligament. We'll place him into a removable. All questions were answered.
2. Wrist pain, left
Imaging: Xray Wrist Complete Dorsal distal radius fracture noted. Or styloid fracture noted. Questionable widening about the scapholunate interval
Procedure Codes: 73110 X-RAY EXAM OF WRIST
Follow Up: after MRI and for fracture care
I only see 3 elements on the hpi I got expanded HISTORY
complete ros I got a DETAILED EXAM
complete pfsh I got a LOW MDM
Left wrist pain.
HPI:
Appointment type:
New patient - Consult requested by Nextcare Urgent Care
patient is a 55-year-old male who comes in with chief complaint of left wrist pain. He did have a fall onto outstretched arm. Date of injury 1/15/2016. He did have radiographs. This was noted as being fractured. He comes in today for evaluation. He has pain about the wrist. He denies neck pain. He denies numbness or paresthesias in the right upper extremity. He denies any other complaints. Rest makes his pain better. Activity makes his pain worse
.
ROS:
General/Constitutional:
Denies Thirst - Excessive. Denies Chills.
ENT:
Denies Ear Discharge. Denies Bleeding Gums.
Respiratory:
Denies Coughing. Denies Hemoptysis.
Cardiovascular:
Denies Tachycardia. Denies Circulation Problems.
Gastrointestinal:
Denies Bowel Changes. Denies Constipation.
Genitourinary:
Denies Blood in Urine. Denies Frequent Urination.
Musculoskeletal:
Denies Arthritis, denies. Denies Back Pain, denies.
Skin:
Denies Dry/Sensitive Skin. Denies Rash.
Neurologic:
Denies Coordination Problems. Denies Memory loss. Denies Seizures.
Psychiatric:
Denies Anxiety. Denies Depression.
Surgical History: vasectomy .
Family History:
cancer.
Social History:
tobacco- yes
alcohol- yes
divorced.
Medications: None
Allergies: N.K.D.A.
Objective:
Vitals: Wt 175 lbs, BMI 24.40 Index, Ht 5 ft 11 in.
Physical Examination:
Examination of the right hand and wrist reveals no evidence of skin abnormality. He does have swelling about the distal radius. His pain with palpation about the radius and ulna to palpation. Full digital range of motion. No pain with palpation about the remainder the hand. He does have some pain with palpation around the scapholunate articulation. Full elbow and shoulder range of motion. Normal motor sensation pulses skin examination distally.
Assessment:
Assessment:
1. Other extraarticular fracture of lower end of left radius, initial encounter for closed fracture - S52.552A (Primary)
2. Wrist pain, left - M25.532
Plan:
1. Other extraarticular fracture of lower end of left radius, initial encounter for closed fracture
Notes: I had a long discussion with the patient. I did describe doing an MRI of the wrist to evaluate the scapholunate ligament. We'll place him into a removable. All questions were answered.
2. Wrist pain, left
Imaging: Xray Wrist Complete Dorsal distal radius fracture noted. Or styloid fracture noted. Questionable widening about the scapholunate interval
Procedure Codes: 73110 X-RAY EXAM OF WRIST
Follow Up: after MRI and for fracture care