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Case 1-1 LOCATION: Inpatient, Hospital PATIENT: Mike Bahs ATTENDING PHYSICIAN: Loren White, MD CONSULTANT: Timothy Pleasant,...

Case 1-1

LOCATION: Inpatient, Hospital

PATIENT: Mike Bahs

ATTENDING PHYSICIAN: Loren White, MD CONSULTANT: Timothy Pleasant, MD

REASON FOR CONSULTATION: Rule out neck injury.

HISTORY: This patient is a 17-year-old male who was involved in a motor vehicle accident last night. He remembers driving down the road and the next thing he remembers was trying to reach for his cell phone at a stop sign after the accident. He does not remember any of the details. The car apparently went off the road and hit a tree. The patient is amnesiac for the event but does not believe he lost consciousness. His vehicle was apparently traveling 35-40 miles an hour. There was no report that he was ejected from the vehicle.

PAST MEDICAL HISTORY: He had childhood asthma.

MEDICATIONS: None.

ALLERGIES: None.

FAMILY HISTORY: Noncontributory to the present problem. SOCIAL HISTORY: He chews tobacco. Alcohol use is rare.

EXAMINATION: Vital signs show he is afebrile. Pulse 64. Blood pressure 110/50. Neurologic: He is awake, alert, and fully oriented. His cranial nerves are grossly intact. HEENT: His extraocular movements are full. His eyes are conjugate. His pupils are equal. His facial strength is intact. On motor examination, he has grossly normal motor strength bilaterally in the upper and lower extremities. His reflexes are normal and symmetric at the biceps, triceps, and brachioradialis. The ankle jerks and the knee jerks are normal and symmetric. Gait is not tested. Sensory examination is grossly intact to light touch. Spine examination: The patient’s cervical collar was removed. He has no tenderness to palpation of the cervical spine whatsoever.

The x-rays of the cervical spine, as well as the CT scan of the cervical spine, were reviewed. No fractures or subluxations are noted. CT scan of the head was reviewed, and it is negative for any intracranial pathology.

IMPRESSION/PLAN: In summary, we have a 17-year-old male involved in a motor vehicle accident. He has a mild concussive head injury, as evidenced by his amnesia, and I believe he did lose consciousness for a brief period; however, the exact amount of time for his loss of consciousness is unknown. There is no evidence of any cervical spine injury. The patient is neurologically normal. He does not need to wear a cervical collar. I explained to him and his

mother, Gloria, that if the patient develops any weakness, numbness, or tingling in the arms or legs, trouble with his balance, sleepiness, vomiting, weakness of one side of the body, or any other symptoms, they should call their physician immediately.

I want to thank Dr. White for asking me to see this patient.

CPT Code(s): _________________

ICD-10-CM Code(s): ________________

Abstracting Questions:

1. What items of Review of Systems (ROS) were documented?

2. Under what report heading(s) would the ROS be found?

3. Was the patient the driver or passenger in the motor vehicle?

Expert Solution

Answer :

ICD 10 CM code for concussive head injury with loss of consciousness is " S06.0 X1A".

CPT code for neck CT scan is 70491.

CPT code for neck X Ray is 72100.

Q. No. 1. Answer :

Review of systems, were documented :

* neurological examination :

Awake, alert and fully oriented.

Strength of extremities, normal motor strength.

Cervical coller has removed.

* sensory examination :

Pupils are equal

Grossly intact to light touch.

Q. No. 2. Answer :

Under two review of systems those are

1. Neurological examination

2. Sensory examination

Q. No. 3. Answer :

Patient is driver in the motor vehicle.

Nightingale answered 2 years ago

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