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:
Denies Dyspnea on Exertion and Edema
Admits Able to Conduct Usual Activities and Comfortable
Denies Apparent Distress and Change in Strength
Admits Myalgia and Bruising under nail bed L 1st toe .
Denies Decreased Range of Motion , Joint Pain and Swelling
Denies Numbness and Paresthesia
Admits New Lesions
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
Patient currently takes no medication
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
Appearance: No distress, Alert and oriented x 3
Respiratory Effort: No acessory muscle use no distress
circ intact distally L 1st toe
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
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.
Subungual hematoma - L60.8