lataashwini23@gmail.com
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I was thinking for coding 10140 but was not sure .
Chief Complaint: L 1st toe/toenail pain History of Present Illness: Dropped heavy ramp on L 1st toe yesterday, since has had throbbing pain with bleeding under toenail. No bruising, no swelling of toe Review of Systems: Cardiovascular: Denies Dyspnea on Exertion and Edema General: Admits Able to Conduct Usual Activities and Comfortable Denies Apparent Distress and Change in Strength Musculoskeletal: Admits Myalgia and Bruising under nail bed L 1st toe . Denies Decreased Range of Motion , Joint Pain and Swelling Neurological: Denies Numbness and Paresthesia Respiratory: Denies Dyspnea Skin: Admits New Lesions Vital Signs: Temp 96.40 F, Pulse 71 b/m , Respiration 16 b/m, BP 130/80 mm/Hg SAO2 98% Taken on Jan 16, 2020 at 10:03 AM by Miss Porter, Melissa Allergies: Codeine (Drug) Current Medications: Patient currently takes no medication Past Medications: Cefdinir 300 MG Oral Capsule: 1 Capsule(s) every 12 hours , Start 10/31/2019, Qty 20 Capsule(s) For 10 Day(s), - Auto Completed on 01/16/2020 Neomycin-Polymyxin-HC 3.5-10000-1 Otic Suspension: 3 drops in affected ear TID x 7 days., Start 10/31/2019, Qty 10 Milliliters For 7 Day(s), - Auto Completed on 01/16/2020 Amoxicillin 500 MG Oral Tablet: 1 Tablet(s) every 12 hours , Start 10/26/2019, Qty 20 Tablet(s) For 10 Day(s), - Auto Completed on 01/16/2020 Physical Exam: Constitutional Appearance: No distress, Alert and oriented x 3 Respiratory Respiratory Effort: No acessory muscle use no distress Cardiovascular circ intact distally L 1st toe Musculoskeletal TTP to l distal 1st toe, subungual hematoma, but no other swelling/bruising, FRoM 1st toe, mild pain with movement. Skin and Subcutaneous Tissue Subungual hematoma L 1st toenail Neurologic limping gait Psychiatric Judgment and Insight: Appears appropriate; Mood and Affect: Affect appropriate XR L 1st toe = No Fx, normal alignment, no STS Assessment And Plan: 1) L 1st toe subungual hematoma - 2 burr holes made with 18g needle, small about of serosanguinous fluid expressed, suspect this blood has coagulated. Pt had some relief after drainaged. Advised warm soaks. Diagnoses: Subungual hematoma - L60.8 |