High School

**Chief Complaint:** Right shoulder injury.

**Mode of Arrival:** Private vehicle.

**History of Present Illness:**
- The patient is a 59-year-old male who was injured by a revolving door at a supermarket.
- The door hit him across the right side of his chest, anteriorly and posteriorly.
- An employee assisted him out of the door.
- He denies current shortness of breath but experienced the wind being knocked out of him.
- He reports pain in the anterior and posterior chest wall, especially medial to the scapula.
- No numbness, tingling, or weakness in the right arm, but it is painful and difficult to move.
- No head or neck injury, though he had temporary spasms on the left side of the neck.
- He has not taken any pain medication.

**Review of Systems:**
- Negative for fevers, chills, weight loss, neck pain, numbness, tingling, weakness, nausea, vomiting, shortness of breath, hemoptysis, or cough.
- All other systems reviewed and negative except as noted.

**Physical Examination:**
- General: Awake and alert, appears nontoxic.
- Vital Signs: Temp = 98.3°F, Pulse = 81 bpm, Respirations = 16/min, BP = 134/81 mmHg, Pulse oximetry = 95% on room air.
- HEENT: Normocephalic and atraumatic.
- Neck: Non-tender, trachea midline, no subcutaneous emphysema.
- Heart: Regular rate and rhythm, no murmurs.
- Lungs: Clear bilaterally, no wheezes, crackles, or rhonchi.
- Thorax/Chest Wall: Mild tenderness anteriorly, distinct tenderness posteriorly near scapula, no bruising or deformity.
- Extremities: Warm and dry, normal grip strength, no clubbing, cyanosis, or edema, normal pulse, and sensation.
- Abdomen: Soft, non-distended, non-tender.

**Diagnostics:**
- Chest X-rays (PA and lateral) and right shoulder X-rays obtained.

**ED Course:**
- Patient received 2 mg Dilaudid and 1 mg Ativan, arm placed in sling, and discharged home.

**Medical Decision Making:**
- Anterior and posterior chest wall contusion diagnosed.
- Unclear why shoulder movement is difficult; neurologically intact.
- X-rays show no fracture or dislocation.
- Discharged with instructions to use ice packs, prescribed pain medications, and return if symptoms worsen.

**Impression:**
1. Anterior and posterior chest wall contusion.
2. Right shoulder injury.

**Plan:**
- Discharge home.
- Return if symptoms worsen.
- Use sling for comfort.

**Question:** What diagnosis code(s) are reported?

Answer :

Final answer:

The diagnosis codes reported for this patient are contusion of the anterior chest wall, contusion of the posterior chest wall, and shoulder injury.

Explanation:

Diagnosis codes, also known as ICD codes (International Classification of Diseases codes), are alphanumeric codes used by healthcare professionals, medical coders, and insurance companies to classify and document medical diagnoses and conditions. Healthcare professionals, medical coders, and billers must select the most accurate and specific diagnosis code based on the patient's condition and clinical documentation to ensure proper billing, reimbursement, and clinical care.

The diagnosis codes reported for this patient's condition would be:

  1. Contusion of anterior chest wall (diagnosis code: S20.00XA)
  2. Contusion of posterior chest wall (diagnosis code: S20.10XA)
  3. Shoulder injury, unspecified side (diagnosis code: S49.90XA)

These codes accurately represent the patient's chief complaint and the findings from the physical examination and diagnostic tests.

Learn more about the topic of Diagnosis codes here: https://brainly.com/question/34698427

#SPJ11

Other Questions