I need some opinions please!! Physician charged closed treatment but I'm not sure about the wording "she likely has an occult fracture" and "questionable irregularity of the radial neck". Is this enough to consider diagnosis definitive or would you lean toward coding the symptoms and no fracture charge?
Thanks,
Lisa
See excerpt of note below...
HPI: The patient is a 51-year-old female, who presents today for evaluation of right forearm pain. She is seen in consultation with Dr. X. She notes that her pain began after a fall on August 20. The pain is located over the dorsal aspect of the forearm. She does feel some tenderness proximally into her elbow. She is able to move her elbow, but states that it feels somewhat stiff. No numbness or tingling distally. She has mild wrist pain.
X-ray: X-rays of the elbow reveal questionable irregularity of the radial neck. There is an anterior and posterior fat pad sign.
Plan/Assessment: I discussed with the patient that she likely has an occult proximal radius fracture. Typically, these can be treated nonoperatively, and she can use a sling for the first week or so after this injury. She should have a follow-up x-ray to ensure that she is not losing alignment of her fracture. She lives in XXX, and will follow-up with an orthopedist there. Once comfortable, she should pursue range of motion exercises out of the sling.
Thanks,
Lisa
See excerpt of note below...
HPI: The patient is a 51-year-old female, who presents today for evaluation of right forearm pain. She is seen in consultation with Dr. X. She notes that her pain began after a fall on August 20. The pain is located over the dorsal aspect of the forearm. She does feel some tenderness proximally into her elbow. She is able to move her elbow, but states that it feels somewhat stiff. No numbness or tingling distally. She has mild wrist pain.
X-ray: X-rays of the elbow reveal questionable irregularity of the radial neck. There is an anterior and posterior fat pad sign.
Plan/Assessment: I discussed with the patient that she likely has an occult proximal radius fracture. Typically, these can be treated nonoperatively, and she can use a sling for the first week or so after this injury. She should have a follow-up x-ray to ensure that she is not losing alignment of her fracture. She lives in XXX, and will follow-up with an orthopedist there. Once comfortable, she should pursue range of motion exercises out of the sling.