[Verified Answer]: EMERGENCY ROOM REPORT CHIEF COMPLAINT:…

EMERGENCY ROOM REPORT CHIEF COMPLAINT: INJURY TO RIGHT WRIST. HISTORY OF PRESENT ILLNESS: This 59-year-old tripped over her water hose this morning, sustaining injury to the right wrist. No other injury. She is in here for evaluation. PAST MEDICAL HISTORY: Remarkable for surgical thyroidectomy. MEDICATIONS: Include thyroid supplement. ALLERGIES: NONE KNOWN. PHYSICAL EXAM: GENERAL: This is a 59-year-old white female with some swelling to the right wrist area. Her MCP, PIP and DIP joints are otherwise WNL, with full ROM of the right elbow. She is tender over the distal right radius. X-ray demonstrated a comminuted fracture of the distal right radius, with joint space involve- ment, however, her fragments appear in good position at this time. She did have a chip off the ulna styloid as well. No other fracture is appreciated. HOSPITAL COURSE: A bivalve fiberglass splint was placed, and she will follow up with Dr. Redi who I initially tried to contact via phone, however, he was in the OR and a message was left for him that this patient will be following with him in the office this next week. ASSESSMENT: RIGHT DISTAL RADIUS FRACTURE AND ULNA STYLOID FRACTURE. PLAN: Bivalve splint, ice, elevate. She was offered something for pain, but felt she did not require it. She will follow up with Dr. Redi this next week, and return for any marked worsening symptoms or problems and/or prn. need IDC-10-CM CODES AND CPT CODES