Allysaloop
Contributor
Hello there! Was wondering if anyone can help me figure out why moderate conscious sedation wasn't coded for this case as I was marked wrong on Practicode. I wanted to ask this in the post coding notes but the page glitched! 
Thank you for your assistance! 
Thank you for your assistance! Emergency Department Report
Insurance: Medicare
Sex: F
AGE: 93
DOS: 01/01/20XX
Time Seen: 05:08
Arrived- By ambulance. Historian- patient and EMS personnel.
HISTORY OF PRESENT ILLNESS
Chief Complaint- FALL. Location of injuries- head and right shoulder. The injury occurred just prior to arrival.
Tripped and fell in the hallway. Occurred at her private residential home.
The patient complains of severe pain. The patient sustained a blow to the head. No neck pain, loss of consciousness or seizure. Not dazed.
REVIEW OF SYSTEMS: The patient sustained skin laceration to the face. No numbness, dizziness, loss of vision, hearing loss or chest pain. No difficulty breathing, weakness, headache, nausea or vomiting. All systems otherwise negative, except as recorded above.
PAST HISTORY: Risk factors for neck injury- age over 40. Denies the following risk factors for neck injury - history of ankylosing spondylitis, severe osteoarthritis and prior neck injury.
Medications: Toprol XL Oral.
Allergies: NKDA.
SOCIAL HISTORY: Nonsmoker. No alcohol use or drug use.
ADDITIONAL NOTES: The nursing notes have been reviewed.
05:09 01/01/20XX Weight: 62.6 kg stated. --05:09 Kristey R., RN.
PHYSICAL EXAM
Appearance: Alert. Oriented X3. No acute distress. (05:25. HR: 59 regular. RR: 22 regular. Temp: 98.5. --05:25 Kristey R., RN. 05:09 01/01/20XX Weight: 62.6 kg stated. --05:09 Kristey R., RN.).
Vital Signs: Have been reviewed.
Head: No Battle's sign or raccoon eyes.
Eyes: Pupils equal, round and reactive to light. EOM intact. Right periorbital area: mild tenderness and swelling, small ecchymosis and 2.0 cm laceration of the lateral aspect of the periorbital area. No deformity. No entrapment of extraocular muscles or gaze palsy.
ENT: No dental injury. Pharynx normal. Right ear: No hemotympanum. Left ear: No hemotympanum.
Neck: Painless ROM. Non-tender.
CVS: Cardiac murmur present. Pulses normal.
Respiratory: Breath sounds normal. Chest nontender. No rales, wheezes or rhonchi.
Abdomen: No visible injury. Soft and nontender. Bowel sounds normal. No organomegaly. No mass. Femoral pulses equal.
Back: No back tenderness. ROM normal.
Skin: Skin warm and dry. Normal skin color. Normal skin turgor.
Extremities: Right shoulder: deformity and severe tenderness. Limited ROM. Neurovascular intact distally. No abrasion or ecchymosis. Pelvis stable. No lower extremity edema.
Neuro: Oriented X 3. No motor deficit. No sensory deficit. Reflexes normal.
LABS, X-RAYS, AND EKG
Rt Shoulder X-ray: (IMPRESSION: Anterior shoulder(humerus) dislocation. The X-rays were independently viewed and interpreted by the radiologist.
Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process.
PROGRESS AND PROCEDURES WITH (Conscious Sedation) 30 min performed by Dr. Jones.
Reduction of Dislocated Shoulder: IV established. O2 administered by Dr. Jones. Placed on pulse oximeter and cardiac monitor. Neurovascular exam intact pre-procedure. Given Morphine and Etomidate. The right shoulder was reduced using traction-countertraction technique and scapular manipulation technique. Reassessed post-procedure. Neurovascular status intact. Deltoid sensation normal. Exam indicated reduction. Confirmed reduction on X-ray. Shoulder immobilizer applied.
Laceration Repair: Location: Periorbital face. Length: 2.0 cm. Complexity: simple (sutured). 2.0 cm laceration of the lateral aspect of the periorbital area.
Wound depth/shape- subcutaneous and linear. Wound is clean. No foreign body present. Distal neuro/vascular/tendon status normal. Local anesthesia provided using 0.50% Marcaine with epi. Prepped with Shur-Clens. Wound explored, cleansed and irrigated with normal saline. Closure of skin: interrupted 6-0 nylon. Post-procedure: she is stable and there are no complications. Bleeding is controlled and neuro-vascular status is intact distal to the wound.
Course of Care: Female with mechanical fall tonight. She has deformity of R shoulder and R periorbital lac. No other injuries noted.
Xray confirms dislocation of anterior humerus right shoulder
Conscious sedation by Dr Jones and relocation of the shoulder myself. Pt had transient episode of hypotension which quickly resolved after etomidate metabolized. She is back to her baseline mentation and denies any pain at present.
Consult obtained from orthopedics, agrees to see in FU. Case discussed. Phone consult only. Will see patient in the office.
Consult obtained from internal medicine. DR Andrews, agrees to admit for management. Dr Kramer to FU on labs prior to admission. Case discussed. Phone consult only. Will see patient in the hospital.
Patient counseled in person regarding the patient's stable condition, test results, diagnosis and need for follow-up. Old medical records reviewed (2 prior EKGs with LBBB noted).
Disposition: Admitted.
CLINICAL IMPRESSION
Anterior humerus dislocation right shoulder
Fall in private home
Laceration periorbital.
UTI
INSTRUCTIONS
Follow-up with: Ortho, MURRAY
Follow up tomorrow. Call for an appointment.
Brayden Kramer
Electronically signed by BRAYDEN KRAMER 01/01/20XX
Any laboratory data incorporated in this document has been entered by the emergency clinician and may have been summarized or otherwise modified. The original full report is available in Meditech. Please refer to PCI for the Performing site information.
ADDITIONAL NOTES
05:09 01/01/20XX Weight: 62.6 kg stated. --05:09 Kristey R., RN.
LABS, X-RAYS, AND EKG
Chest X-ray: (FINDINGS: Single view chest. There is diffuse osteopenia. No rib fractures are identified. Heart size is upper limits normal. Aorta is atherosclerotic. Pulmonary vessels are normal in caliber and course. Lung volumes are normal. Lungs are clear. Is no evidence of pneumothorax, hemothorax, or pulmonary contusion.
IMPRESSION: No evidence of acute cardiopulmonary disease.
Brayden Kramer
Electronically signed by BRAYDEN KRAMER 01/01/20XX
Reported and Signed by: Brayden Kramer
The X-rays were interpreted contemporaneously by me. Technique: good. The X-rays were independently viewed by me. Post procedure films: show good alignment.
Laboratory Tests: Laboratory tests have been ordered, with results reviewed and considered in the medical decision making process. 0313:YJ:CG00047R: (COLL: 01/01/20XX 05:27) (MsgRcvd 001/01/20XX 07:27)
Final results
Laboratory Test Value
HOLD TUBE FOR COAG SEE NOTE
0313:YJ:C00149S: (COLL: 01/01/20XX 05:27) ( MsgRcvd 01/01/20XX 07:46) Final results
Laboratory Test Value
SODIUM 140
POTASSIUM 4.3
CHLORIDE 105
CARBON DIOXIDE 21.0
ANION GAP 14
GLUCOSE 148
BLOOD UREA NITROGEN 27
CREATININE 0.80
GLOMERULAR FILTRATION RATE > 60
TOTAL PROTEIN 6.7
ALBUMIN 3.3
CALCIUM 9.1
BILIRUBIN TOTAL 0.30
SGOT/AST 10
SGPT/ALT 23
ALKALINE PHOSPHATASE 47
0313:YJ:U00009S: (COLL: 01/01/20XX 07:50) ( MsgRcvd 01/01/20XX 08:27) Final results
Laboratory Test Value
UA COLOR PALE YELLOW
UA APPEARANCE CLEAR
UA GLUCOSE DIPSTICK NORM
UA BILIRUBIN DIPSTICK NEG
UA KETONE DIPSTICK NEG
UA SPECIFIC GRAVITY 1.015
UA BLOOD DIPSTICK NEG
UA PH DIPSTICK 5.0
UA PROTEIN DIPSTICK 25
UA UROBILINOGEN DIPSTICK NORM
UA NITRITE DIPSTICK POS
UA LEUKOCYTE ESTERASE DIPSTICK 100
UA RBC 2-5
UA WBC 25-50
UA BACTERIA 4+
UA SQUAMOUS CELLS 10-15
ADDIT URINALYSIS TESTS? NO
URINE CULTURE NEEDED? YES
0313:YJ:H00102S: (COLL: 01/01/20XX 05:27) ( MsgRcvd 01/01/20XX 07:38)
Final results
Laboratory Test Value
WHITE BLOOD CELL 7.1
RED BLOOD CELL 3.86
HEMOGLOBIN 12.9
HEMATOCRIT 38.0
MEAN CELL VOLUME 98.5
MEAN CELL HGB 33.5
MEAN CELL HGB CONCENTRATION 34.0
RED CELL DISTRIBUTION WIDTH 12.5
PLATELET COUNT 241
MEAN PLATELET VOLUME 8.9
NEUTROPHIL % 51.5
LYMPHOCYTE % 37.1
MONOCYTE % 7.0
EOSINOPHIL % 3.7
BASOPHIL % 0.7
NEUTROPHIL # 3.7
LYMPHOCYTE # 2.6
MONOCYTE # 0.5
EOSINOPHIL # 0.3
BASOPHIL # 0.1
MANUAL DIFF REQUIRED? NO
SMEAR REVIEW ? NO
NP AUTO DIFF NO
PROGRESS AND PROCEDURES
Reduction of Dislocated Shoulder with Conscious Sedation: Time: intraservice is 30 mins by Dr. Jones
IV established. Placed on pulse oximeter and cardiac monitor. Given Etomidate. (Dr. Jones administered the 10 mg IV etomidate with appropriate sedation and I, (Dr. Kramer) reduced the dislocation.).
Course of Care: Please refer to Dr. Kramer H and P. This patient suffered a mechanical fall and an accompanying right shoulder dislocation that was reduced in the ED. she also suffered a right facial laceration that was repaired and sutures should be replaced with steristrips or dermabond in 5-7 days. The patient has evidence of a UTI and was given Rocephin after blood cultures. a breakfast was ordered for her. She is amenable to being admitted given this is her dominant arm and she lives independently. Dr. Thomas will kindly admit. Also she received at least 500 cc NS while on the ED.
Patient/ family counseled.
Medical Decision Making: Ordered tests include x-rays of the extremities. The patient has improved. The patient requires medical therapy and pain control. A consult has been requested. The patient is to be admitted.
Disposition: Admitted to Med-Surg. Condition: stable.
CLINICAL IMPRESSION
Anterior dislocation right humerus shoulder
Superficial laceration to periorbital
Fall on same level by stumbling in private home
UTI
Brayden Kramer
Electronically signed by BRAYDEN KRAMER 01/01/20XX
Any laboratory data incorporated in this document has been entered by the emergency clinician and may have been summarized or otherwise modified. The original full report is available in Meditech. Please refer to PCI for the Performing site information.