mags76
New
I am having a hard time understanding the exam part of a 1997 specialty specific exam. The bullets are what I am having a hard time with. First, what would this be coded and can someone help me with the identifying the bullets. Second, when you are coding by 1997 guidelines, you have to also examine other areas correct? ie skin, neuro. Thank you anyone who helps me, I have been struggling with this all day.
81 year old female who comes in for a referral from . She presents for left hip pain. This injury is the result of a slip/fall. Her symptoms have been present for 4 weeks. The injury happened on 7/27/12.
She describes her pain as sore and severe. Her pain is worse with activities. Her symptoms are worse when standing, bending, climbing stairs, twisting, moving, and walking. Previous studies performed to evaluate this condition include X-rays.
She notes improvement in her symptoms with ice, rest, assistive device, and narcotic medication.
Review of Systems
General: Thyroid, Blood Clots
Cardiovascular: denies chest pains,fainting,ankle swelling,leg swelling,shortness of breath with exercise or murmur
Respiratory: Chronic Bronchitis
Past Medical History
Thyroid Problems, Dizziness, Fainting, Chronic Bronchitis, Shortness of Breath, Pneumonia, Blood Clots, Ulcers
Past Surgical History
Broken R Shoulder - 1983
SHoulder Roatation - 1975, 1976
Ulcer - 1972
Tonsils - 1943
Hysterectomy - 1997
Appendix - 1949
Fibromyalgio - 1963
Back Sugery - 2002
Spinal Cord Stimulation -2005
Cataracts - 2009
Back surgery - 2010
Family Medical History
Stroke, Heart Disease, Pacemaker, Cancer, Blood Clots
Social History
Tobacco Use (never smoker)
Alcohol Use (never)
Drug Use (No)
Marital Status: Widowed
Allergies: No known drug or environmental allergies.
Medication: PROPRANOLOL HCL 10 MG TABS (PROPRANOLOL HCL)
LEVOTHYROXINE SODIUM 75 MCG TABS (LEVOTHYROXINE SODIUM)
CLONAZEPAM 1 MG TABS (CLONAZEPAM)
GABAPENTIN 300 MG CAPS (GABAPENTIN)
Physical Exam
Vital Signs
Ht: 61ins Wt: 126lbs Temp: 98.4 deg F. Temp site: oral Pulse rate: 60 BP: 134/64
Body Mass Index: 23.89
Inspection
Pain/Tenderness: greater trochanter, with rotation
Gait: with cane
Neurovascularly intact
Active ROM
Abduction: painful
Flexion: painful
Internal rotation: painful
External rotation: painful
Muscle Strength
Abduction: 4/5
Adduction: 4/5
Flexion: 3/5
Extension: 3/5
X ray: Left Hip
Three views
Findings: Subcapital fracture of left hip with minimal displacement.
Impression & Recommendations:
Problem # 1: FRACTURE, FEMUR, INTERTROCHANTERIC REGION, LEFT
This injury needs to be surgically fixated with cannulated pins. We will get her scheduled for surgery. All risks and benefits were discussed and her questions and concerns for addressed.
81 year old female who comes in for a referral from . She presents for left hip pain. This injury is the result of a slip/fall. Her symptoms have been present for 4 weeks. The injury happened on 7/27/12.
She describes her pain as sore and severe. Her pain is worse with activities. Her symptoms are worse when standing, bending, climbing stairs, twisting, moving, and walking. Previous studies performed to evaluate this condition include X-rays.
She notes improvement in her symptoms with ice, rest, assistive device, and narcotic medication.
Review of Systems
General: Thyroid, Blood Clots
Cardiovascular: denies chest pains,fainting,ankle swelling,leg swelling,shortness of breath with exercise or murmur
Respiratory: Chronic Bronchitis
Past Medical History
Thyroid Problems, Dizziness, Fainting, Chronic Bronchitis, Shortness of Breath, Pneumonia, Blood Clots, Ulcers
Past Surgical History
Broken R Shoulder - 1983
SHoulder Roatation - 1975, 1976
Ulcer - 1972
Tonsils - 1943
Hysterectomy - 1997
Appendix - 1949
Fibromyalgio - 1963
Back Sugery - 2002
Spinal Cord Stimulation -2005
Cataracts - 2009
Back surgery - 2010
Family Medical History
Stroke, Heart Disease, Pacemaker, Cancer, Blood Clots
Social History
Tobacco Use (never smoker)
Alcohol Use (never)
Drug Use (No)
Marital Status: Widowed
Allergies: No known drug or environmental allergies.
Medication: PROPRANOLOL HCL 10 MG TABS (PROPRANOLOL HCL)
LEVOTHYROXINE SODIUM 75 MCG TABS (LEVOTHYROXINE SODIUM)
CLONAZEPAM 1 MG TABS (CLONAZEPAM)
GABAPENTIN 300 MG CAPS (GABAPENTIN)
Physical Exam
Vital Signs
Ht: 61ins Wt: 126lbs Temp: 98.4 deg F. Temp site: oral Pulse rate: 60 BP: 134/64
Body Mass Index: 23.89
Inspection
Pain/Tenderness: greater trochanter, with rotation
Gait: with cane
Neurovascularly intact
Active ROM
Abduction: painful
Flexion: painful
Internal rotation: painful
External rotation: painful
Muscle Strength
Abduction: 4/5
Adduction: 4/5
Flexion: 3/5
Extension: 3/5
X ray: Left Hip
Three views
Findings: Subcapital fracture of left hip with minimal displacement.
Impression & Recommendations:
Problem # 1: FRACTURE, FEMUR, INTERTROCHANTERIC REGION, LEFT
This injury needs to be surgically fixated with cannulated pins. We will get her scheduled for surgery. All risks and benefits were discussed and her questions and concerns for addressed.