87 year old female presents with right posterior thigh pain of gradual onset this morning. Pain is sharp/stabbing, sometimes radiates down to her knee. She felt a similar pain one week ago which improved significantly with leg exercises prescribed by her physiotherapist. Denies any numbness, tingling or weakness. Denies any recent surgeries, prolonged immobilization or
history of DVT/PE. No recent falls or injuries.
Medical Decision Making (MDM) :
Well appearing 87 year old female with no recent trauma/falls presents with right posterior thigh pain that was present one week ago, resolved with leg exercises and recurred this morning. In tact distal neurovascular exam. She was bilat 1+ pitting edema that is equal on both sides and I did not think a DVT was likely. I ordered an xray of the patient’s hips which did not show any acute fractures or dislocations. I also ordered an xray of the patient’s lumbar spine which showed a compression deformity but this is not likely acute or the cause of the patient’s symptoms. Patient was comfortable with treating her symptoms conservatively with Tylenol at home as this improves her symptoms. I recommended return to physical activity as tolerated. Counseled and educated patient on treatment plan and risks and benefits of treatment. Patient understands that we are not able to diagnose all conditions in the emergency department, and that although at this time there are no worrisome symptoms and patient appears to be stable, patient will need to return at once if any recurrent, worsening, or new symptoms. Provided literature in after visit summary.
Assessed for patient understanding and answered all of the patient’s questions completely.
ED Diagnosis (Current Problem List) :
Associated ICD-10-CM Code Status Onset
Pain of right thigh M79.651 – PAIN IN RIGHT THIGH Active
Past Medical History :
PMH: Atrial fibrillation
Allergies
No Known Drug Allergies
Home Medications
Acetaminophen, 500 milligram orally every 6 hours (Duration: 8 days)
Coumadin, 4 milligram orally 5 times per week, Discharge Dose Due: 04/09/2016 21:00
HYDROcodone-acetaminophen 5 mg-325 mg, 1 tablet orally every 4 hours, Start Date: 07/20/2018
Lipitor, 10 milligram orally every evening, Discharge Dose Due: 04/09/2016 21:00
MECLIZINE TABLET, 25 MG ORAL EVERY 8 HOURS PRN, Start Date: 04/08/2016, Discharge Dose Due: 04/09/2016 13:00
Synthroid, 125 microgram orally every day, Discharge Dose Due: 04/10/2016 06:00
Toprol XL, 12.5 milligram orally every day, Discharge Dose Due: 04/10/2016 09:00
Tylenol, 650 milligram orally Per package directions, Discharge Dose Due: 04/09/2016 13:00
Warfarin, 2 milligram orally twice a week, Discharge Dose Due: 04/11/2016 21:00
Immunizations
Influenza, seasonal, injectable, preservative free – 140 (2015), Pneumococcal conjugate PCV 13 – 133 (2012)
Social History
Tobacco Use
Never smoker
None Reported : TOBACCO HISTORY Last Documented By: , RN on 09/16/2015 13:36
Alcohol Use
None Reported : ALCOHOL HISTORY Last Documented By: RN on 09/16/2015 13:36
Recreational Drug Use
None Reported : RECREATIONAL DRUG HISTORY Last Documented By: RN on 09/16/2015 13:36
Review Of Systems
ROS: Constitutional: No fevers, chills, night sweats.
Head: No headaches, head injury.
Neurologic: No fall. No numbness, tingling, weakness, syncope.
Musculoskeletal: No back pain. No neck pain. Positive right posterior thigh pain.
Peripheral vascular: No persistent bleeding. No cyanosis. Positive anticoagulation therapy.
Skin: No rash. No laceration. No ecchymosis.
ROS:
Vital Signs
Most Recent Set of Vitals:
BP: 167/81 07/20/2018 11:59
Pulse: 77 07/20/2018 11:59
Temp: 36.8 C 07/20/2018 11:59
Resp: 18 07/20/2018 11:59
02 Sat: 98%(Room Air) 07/20/2018 11:59
Calculated BMI: 26.5 07/20/2018 11:59
Physical Exam
GENERAL
Vitals: Reviewed by me.
Constitutional: Well developed, well nourished. No acute distress.
Head: Atraumatic, Normocephalic.
Musculoskeletal: No obvious deformity or bony step-offs. Full range of motion.
No tenderness to palpation at the right anterior/lateral/posterior right hip. Tender to palpation in the midline right posterior thigh where illustrated.
Neurologic exam: Awake, alert, and oriented to time, place, and person. CNII-XII grossly intact. Motor strength is 5/5. No sensory deficits with light touch. Patellar tendon reflexes 2+ bilaterally. No deficits with finger-nose-finger, or rapid alternating movements. Gait is not antalgic. Bears weight without assistance
Peripheral Vascular: Femoral, posterior tibial and dorsalis pedis pulses 2+ and equal. Capillary refill less than 3 seconds. 1+ bilateral lower extremity edema.
Skin: Warm, dry.
Date / Time: Study:
EXAM:
XR SPINE LUMBAR (2V-3V)
REASON FOR STUDY:
M25.551: PAIN IN RIGHT HIP, :
CLINICAL HISTORY:
Pain in right hip.
CPT code :99284
72100
ICD 10: M25551 , M79651 , R609 , I4891 , Z7901