Which of the following mechanism of injuries does NOT warrant spinal motion restriction?
A) Hanging patient
B) Lightning injuries
C) Unresponsive trauma patient
D) Burn injuries
D
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SUBJECTIVE: This 25-year-old male presents with a small laceration to his right distal thigh. He notes he was in a store this evening, when he moved to avoid some people in the aisle, and struck his leg against a metal shelf resulting in this laceration. The patient is not current on his tetanus immunization. He originally was not going to come in for sutures, but the laceration is near his knee
and he has to work on his knees a lot as an auto body repairman. OBJECTIVE: Physical exam reveals a well-developed, well-nourished male. He is alert and oriented and in no acute distress. Vital signs are within normal limits. Exam of his right distal thigh reveals a 2.5 cm linear laceration through the dermis just proximal to the knee. The wound was cleaned, irrigated with normal saline, injected with 1% Xylocaine with epinephrine. It was then sutured with 4-0 interrupted nylon sutures. Neosporin ointment and a dressing were placed over the wound. The patient was also given a DT booster. ASSESSMENT: Laceration, right distal thigh, sutured. PLAN: Wound care instructions include suture removal in 10 - 14 days. He is to watch closely for any signs of infection and return to the emergency room should this occur. ICD-9-CM diagnosis code(s): _____________________ __________________________________________________ ICD-10-CM diagnosis code(s): _____________________ __________________________________________________ CPT code(s) with modifier, if applicable: _____________________ What will be an ideal response?
The ________________________ is a document that is completed on the first visit to the patient's home. The document should include the patient's present illness, significant past history, review of all systems/physical assessment, medications, psychological, social, and economic factors, emergency plans, and skilled nursing performed that day, and incorporate the required OASIS data elements.?
Fill in the blank(s) with correct word