Jim,
I get a lot of found down, and Auto accident. I can't find my Abdominal Pain but let you send you another that I feel is 99284 but noted as Critical Care. Maybe you all would think this is more of a 99283 or 99285 ??
REPORT TITLE: Trauma and Critical Care Sugery Consultation
CHIEF COMPLAINT: Status post motor vehicle collison
PERTINENT TRAUMA CRITERIA: The patient was deemed to meet trauma activation criteria and was activated as a code trauma. The pt was brought to the Medical Center as the regional trauma center and I was summoned to see the pt as the trauma surgeon on duty and was there to perform the emergency assessment trauma evaluation and critical care management according to the Americal college of Surgeons Advanced Trauma Life Support Protocol. The eval on this pt on an emergency basis is mandated by state and federal law as well as by the county and our trauma emergency department. The Americal College of Surgeons advanced trauma life support protocol was followed in the eval, trauma management, and critical care of this patient.
HISTORY OF PRESENT ILLNESS: The pt is a male who was restrained driver in a motor vehicle collison. He had no loss of consciousness but was complaining of left hand and knee pain. He was activated as a code trauma and arrived by ambulance at 0:00 am on _/_/11. In accordance to the Americal college of surgeons advanced trauma life support protocol, I initiated my primary survey
PARAMEDICA REPORT:
PRIMARY SURVEY A.AIRWAY Airwary was open adn patent B.BREATHING pt breathing spontaneously w/o paradoxical chest wall motion. C. CIRCULATION pt had warm palpable pulses and brisk capillary refill in all four extremities D. DEFORMITY AND DISABILITY pt had no evidence of long bone or gross body torso deformity E EXPOSURE pt clothes were removed almost entirely and there were no signs of open hemorrhagic lacerations.
GENERAL ASSESSMENT The patient was awake, alert and oriented x3, and had a Glasgow Coma Score of 15. His memory was intact. The pt was able to give me the following past medical history
Chronic Medical disease - none, past surgical history - none, Medications - none, Allergies - None, family history noncontributory
SOCIAL HISTORY Tobacco Use - Denies, Alcohol Use - Denies, Illicit Drug use - Denies
TETANUS TOXOID STATUS up-to-date
REVIEW OF SYSTEMS: Left hand pain
PHYSICAL EXAMINATION AND SECONDAY SURVEY
GENERAL well developed, well nourished male who apprears to be stated age
VITAL SIGNS initial vital signs were blood pressure 120/80, pulse 86, respirations 18 temperature 99
HEAD head examined and found w/o signs of lacerations, abrasions or contusions
EYES pupils were equal, round reactive. sclerae were not icteric. extraocular muscles were intact, good visual acuity
EARS external auditory canals clear no signs of hemotympanum bilaterally, not signs of tympanic membrame injuty no signs of external ear lacerations, abrasions or contusions
POSTERIOR CERVICAL SPINE: The posterior cervical spine was palpated w/o signs of tenderness. The was no bony step-off or crepitus on palpation
ANTERIOR MID-FACE mid face w/o bony step off or lacerations, abrasions or contusions
NOSE Nose w/o signs of nasal septal deviation. No signs of nasal septal hematoma and no signs of rhinorrhea nasal passages w/o lacerations, abrasions or contusions
ORAL CAVITY: Oral cavity w/o signs of lacerations, abrasions, or contusions. No signs of tooth loss or injury
MANDIBLE: mandible was nontender w/o palpable bony deformity. normal occlusion on mandibular bite down technique
ANTERIOR NECK Anterior neck was w/o crepitance. The trachea was in the midline. There were no stridor sounds upon respiration. No distention of the neck veins. No sign of Laceration, abrasions or conusions
ANTERIOR CHEST The chest was clear w/ good breath sounds bilaterally, no wheezes, no rales, no rhonchi no lacerations, abrasions or contusions
HEART heart regular rate and rhythm, no auscultated murmur gallop or rub. no faint or muffled heart sound
ABDOMEN abdomen was non tender, no rebound no guarding no peritoneal signs. no rigidity no distention no lacerations, abrasions or contusions
PELVIS Pelvis was stable upon rocking motion w/o bony step off or crepitance no lacerations, abrasions or contusions
EXTREMITIES The extremities were w/o signs of clubbing, cyanosis, or edema. Pt good palpable pulsesand brisk capillary refill in all four extremities. moved all 10 fingers and woes w/o limitation. Good sensation to light touch and had no pain in all four extremities. There were no signs of lacerations, abrasions or contusions. There multiple small avulsions that are less than 1 cm in length on the left knee and the dorsal aspect of the left hand. No other lesions, lacerations or contusions were noted.
BACK The back was w/o palpable bony deformity on palpation of the entire thoracolumbosacral spine. There was no evidence of lacerations, abrasions or contusions. There was no pain or discomfort on percussion of the costovertebral angles bilaterally
GENITAL/RECTAL external genital and rectal areas were w/o signs of bloddy discharge
NEUROLOGIC Cranial nerves were evaluated, and cranial nerves ____XII were grossly intact.
LABORATORY STUDIES
Hematology white cell 4.3, Hemoglobin and hematocrit of 15.0 and 41.7 platelets 207
Chemistry Soduim 139 potassium 3.5,chloride 103 co2 of 26 bun of 18 creatinine 1.5 glucose of 84 calcium 9.0
Blood alcohol zero
RADIOLOGIC STUDIES Chest xray upright i snegative for intrathoracis trauma
Misc radiologic studies Plain film of left hand in neg for fracture or dislocation. Plain film of left knee is neg for fracute or dislocation
ANALYSIS AND PLAN