Wiki Why was I marked wrong? (Practicode Case ID: OPD7085)

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The documentation:
Emergency Department Report

Sex: M

AGE: 81

DOS: 01/01/20XX

Time Seen: 1329.

Arrived- By private vehicle. Historian- patient and family.

HISTORY OF PRESENT ILLNESS

Chief Complaint- Injury to the left hand and left thumb (possible metal FB). The injury happened possibly 3 months ago while the patient was in the hospital. This was not an incised wound. Thinks there is a broken needle in the thumb. Patient is experiencing mild pain. No other injury.

REVIEW OF SYSTEMS

The patient has had tingling of the left index finger (mild). No swelling, weakness or skin laceration. All systems otherwise negative, except as recorded above.

PAST HISTORY

The patient's dominant hand is the right.

Surgeries: History of previous surgery. Coronary artery bypass graft surgery. Right and left knee prosthesis.

Medications:

Aspirin.

Crestor Oral.

Diovan HCT Oral.

Norvasc Oral.

Toprol XL Oral.

Allergies:

Cephalexin.

SOCIAL HISTORY

Nonsmoker. No alcohol use.

ADDITIONAL NOTES

The nursing notes have been reviewed.

Weight: 103.1 kg measured.

PHYSICAL EXAM

Appearance: Alert. Oriented X3. No acute distress.

Vital Signs: Normal.

CVS: Normal heart rate and rhythm. Heart sounds normal.

Respiratory: No respiratory distress. Breath sounds normal.

Skin: Skin warm and dry. Skin intact.

Extremities: Dorsal left hand: mild tenderness and suspected foreign body (ulnar border of the left thumb just prox to MPJ). No erythema or swelling. No wrist injury. Hand and wrist exam otherwise negative. Extremities otherwise negative.

Neuro, Vascular and Tendons: Vascular status intact. Decreased light touch sensation (left index finger). Tendon function intact.

Neuro: Oriented X 3. Sensory deficit present (left index finger pad). Altered sensation to light touch MISSING_POSTAMBLE.

LABS, X-RAYS, AND EKG

X-Rays: Left hand and thumb

PROGRESS AND PROCEDURES

Course of Care: Pt with definite metallic FB in the subcu tissue of the left first web space - responds to magnetic forces. Will X-ray to eval what type of FB this might be. No signs of infection. D/w pt that this is unlikely to be causing the numbness in the index finger, as it is far from the index finger digital nerves.

14:17. d/w radiologist. we agree that this looks like a metal FB but is not c/w a needle. Will refer pt to hand MD for poss removal of the FB if he decides to do that. with no signs of infection, it would be an elective procedure.

Patient/family counseled.

Differential Diagnosis:

Other possible considerations: metallic FB left first web space.

Clinical Review The patient was given precautions regarding the possibility of foreign body. ?.

CLINICAL IMPRESSION

Retained soft tissue metal foreign body to the left hand and left thumb (- likely very old). No infection.

INSTRUCTIONS

Warnings: GENERAL WARNINGS: Return or contact your physician immediately if your condition worsens or changes unexpectedly, if not improving as expected, or if other problems arise.

Your Current Medications: CONTINUE TAKING THE FOLLOWING MEDICATIONS:

Aspirin

Crestor Oral

Diovan HCT Oral

Norvasc Oral

Toprol XL Oral.

Follow-up with:

CHRISTOPHER Kramer, Orthopedic Surgery

Follow up. Call for an appointment.

Understanding of the discharge instructions verbalized by patient and family.

Jesse Andrews

Electronically signed by JESSE ANDREWS 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.

Clinical Report - Nurses

Patient: Smith, Fausto

DOB: 1/1/1936

TRIAGE

Triage time 12:50 - FB left hand since December; RA - Alert/ambulatory, resp unlabored, pt in NAD. Acuity: LEVEL 4.

Chief Complaint: (FB - Left hand, since December, rates pain 1/10).

(Height 6' 0 (stated)). --12:52 E., ROBIN, R.N.

BP: 131/48. HR: 80. RR: 16. Temp: 96.7 (temporal). O2 saturation: room air -93 percent. Alert. No acute distress. --13:07 E., ROBIN, R.N.

13:07 01/01/20XX Weight: 103.1 kg measured. --13:07 ROBIN E., R.N.

Medications

Aspirin.

Crestor Oral.

Diovan HCT Oral.

Norvasc Oral.

Toprol XL Oral. --1251 (01/01/20XX) ROBIN E., R.N.

Allergies

Cephalexin. --1251 (01/01/20XX) ROBIN E., R.N.

History

Treatment PTA:

None. (Pt states they broke a needle off in my hand upstairs last December).

PAST MEDICAL HX: Hypertension. Pulmonary embolism. Hypercholesterolemia.

SURGERY HX: Coronary artery bypass graft surgery. Knee surgery. Right and left knee prosthesis. Prostatectomy.

SOCIAL HX: Nonsmoker. No alcohol use. Functional assessment: no impairments noted. The nutritional risk assessment revealed no deficiencies. No report of abuse. The patient has not traveled outside the U.S. in the last 3 weeks. The patient was not exposed to tuberculosis, influenza or chicken pox.

Arrived by private vehicle and accompanied by spouse. Historian: patient. Primary physician (Dr.Jones). --12:52 E., ROBIN, R.N.

Interventions

ID band on patient. To treatment room. Ambulatory by hospital staff. Report given to the primary nurse. --13:07 E., ROBIN, R.N.

PHYSICAL ASSESSMENT

1310. Alert. Oriented X 3. Appears in no acute distress. Head non-tender. Respirations not labored. Extremities exhibit normal ROM. Neuro-vascular status intact to the extremity. Dorsal left hand: of the radial hand (magnetic movement noted from inside hand when applied). No tenderness or swelling. Skin intact. Skin is warm and dry. --13:54 b., ray, R.N.

NURSING PROGRESS NOTES

1310. Two patient identifiers checked. Call light placed in reach. Side rails up x 1. Bed placed in lowest position. Brakes of bed on. Patient ready for evaluation. --13:40 b., ray, R.N.

13:40. The plan of care for this patient has been created (x-ray). (EDP eval complete). --13:40 B. Ray, R.N.

1430. (EDP in room discussing dispo). --14:41 B. Ray, R.N.

Jesse Andrews

Electronically signed by JESSE ANDREWS 01/01/20XX

Why is the MDM low? There was prescription drug management, combined with discussion with another provider.
 
The documentation:
Emergency Department Report

Sex: M

AGE: 81

DOS: 01/01/20XX

Time Seen: 1329.

Arrived- By private vehicle. Historian- patient and family.

HISTORY OF PRESENT ILLNESS

Chief Complaint- Injury to the left hand and left thumb (possible metal FB). The injury happened possibly 3 months ago while the patient was in the hospital. This was not an incised wound. Thinks there is a broken needle in the thumb. Patient is experiencing mild pain. No other injury.

REVIEW OF SYSTEMS

The patient has had tingling of the left index finger (mild). No swelling, weakness or skin laceration. All systems otherwise negative, except as recorded above.

PAST HISTORY

The patient's dominant hand is the right.

Surgeries: History of previous surgery. Coronary artery bypass graft surgery. Right and left knee prosthesis.

Medications:

Aspirin.

Crestor Oral.

Diovan HCT Oral.

Norvasc Oral.

Toprol XL Oral.

Allergies:

Cephalexin.

SOCIAL HISTORY

Nonsmoker. No alcohol use.

ADDITIONAL NOTES

The nursing notes have been reviewed.

Weight: 103.1 kg measured.

PHYSICAL EXAM

Appearance: Alert. Oriented X3. No acute distress.

Vital Signs: Normal.

CVS: Normal heart rate and rhythm. Heart sounds normal.

Respiratory: No respiratory distress. Breath sounds normal.

Skin: Skin warm and dry. Skin intact.

Extremities: Dorsal left hand: mild tenderness and suspected foreign body (ulnar border of the left thumb just prox to MPJ). No erythema or swelling. No wrist injury. Hand and wrist exam otherwise negative. Extremities otherwise negative.

Neuro, Vascular and Tendons: Vascular status intact. Decreased light touch sensation (left index finger). Tendon function intact.

Neuro: Oriented X 3. Sensory deficit present (left index finger pad). Altered sensation to light touch MISSING_POSTAMBLE.

LABS, X-RAYS, AND EKG

X-Rays: Left hand and thumb

PROGRESS AND PROCEDURES

Course of Care: Pt with definite metallic FB in the subcu tissue of the left first web space - responds to magnetic forces. Will X-ray to eval what type of FB this might be. No signs of infection. D/w pt that this is unlikely to be causing the numbness in the index finger, as it is far from the index finger digital nerves.

14:17. d/w radiologist. we agree that this looks like a metal FB but is not c/w a needle. Will refer pt to hand MD for poss removal of the FB if he decides to do that. with no signs of infection, it would be an elective procedure.

Patient/family counseled.

Differential Diagnosis:

Other possible considerations: metallic FB left first web space.

Clinical Review The patient was given precautions regarding the possibility of foreign body. ?.

CLINICAL IMPRESSION

Retained soft tissue metal foreign body to the left hand and left thumb (- likely very old). No infection.

INSTRUCTIONS

Warnings: GENERAL WARNINGS: Return or contact your physician immediately if your condition worsens or changes unexpectedly, if not improving as expected, or if other problems arise.

Your Current Medications: CONTINUE TAKING THE FOLLOWING MEDICATIONS:

Aspirin

Crestor Oral

Diovan HCT Oral

Norvasc Oral

Toprol XL Oral.

Follow-up with:

CHRISTOPHER Kramer, Orthopedic Surgery

Follow up. Call for an appointment.

Understanding of the discharge instructions verbalized by patient and family.

Jesse Andrews

Electronically signed by JESSE ANDREWS 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.

Clinical Report - Nurses

Patient: Smith, Fausto

DOB: 1/1/1936

TRIAGE

Triage time 12:50 - FB left hand since December; RA - Alert/ambulatory, resp unlabored, pt in NAD. Acuity: LEVEL 4.

Chief Complaint: (FB - Left hand, since December, rates pain 1/10).

(Height 6' 0 (stated)). --12:52 E., ROBIN, R.N.

BP: 131/48. HR: 80. RR: 16. Temp: 96.7 (temporal). O2 saturation: room air -93 percent. Alert. No acute distress. --13:07 E., ROBIN, R.N.

13:07 01/01/20XX Weight: 103.1 kg measured. --13:07 ROBIN E., R.N.

Medications

Aspirin.

Crestor Oral.

Diovan HCT Oral.

Norvasc Oral.

Toprol XL Oral. --1251 (01/01/20XX) ROBIN E., R.N.

Allergies

Cephalexin. --1251 (01/01/20XX) ROBIN E., R.N.

History

Treatment PTA:

None. (Pt states they broke a needle off in my hand upstairs last December).

PAST MEDICAL HX: Hypertension. Pulmonary embolism. Hypercholesterolemia.

SURGERY HX: Coronary artery bypass graft surgery. Knee surgery. Right and left knee prosthesis. Prostatectomy.

SOCIAL HX: Nonsmoker. No alcohol use. Functional assessment: no impairments noted. The nutritional risk assessment revealed no deficiencies. No report of abuse. The patient has not traveled outside the U.S. in the last 3 weeks. The patient was not exposed to tuberculosis, influenza or chicken pox.

Arrived by private vehicle and accompanied by spouse. Historian: patient. Primary physician (Dr.Jones). --12:52 E., ROBIN, R.N.

Interventions

ID band on patient. To treatment room. Ambulatory by hospital staff. Report given to the primary nurse. --13:07 E., ROBIN, R.N.

PHYSICAL ASSESSMENT

1310. Alert. Oriented X 3. Appears in no acute distress. Head non-tender. Respirations not labored. Extremities exhibit normal ROM. Neuro-vascular status intact to the extremity. Dorsal left hand: of the radial hand (magnetic movement noted from inside hand when applied). No tenderness or swelling. Skin intact. Skin is warm and dry. --13:54 b., ray, R.N.

NURSING PROGRESS NOTES

1310. Two patient identifiers checked. Call light placed in reach. Side rails up x 1. Bed placed in lowest position. Brakes of bed on. Patient ready for evaluation. --13:40 b., ray, R.N.

13:40. The plan of care for this patient has been created (x-ray). (EDP eval complete). --13:40 B. Ray, R.N.

1430. (EDP in room discussing dispo). --14:41 B. Ray, R.N.

Jesse Andrews

Electronically signed by JESSE ANDREWS 01/01/20XX

Why is the MDM low? There was prescription drug management, combined with discussion with another provider.

A conversation between the facility's ER physician and the facility's radiologist would not meet the criteria for discussion with an external provider. (The AMA guidelines specify external provider.)

This chart from the AMA may be helpful to review: https://www.ama-assn.org/system/files/2023-e-m-descriptors-guidelines.pdf
 
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