Sample/Practice/Free Inpatient Coding Report/Charts
DISCHARGE SUMMARY
ADMITTING DIAGNOSES:
1. Fall with
fracture of right hip
2. Dehydration
3. Ascites
DISCHARGE DIAGNOSES:
1. Fracture of
femoral neck and intertrochanteric right hip
2. Severe
osteoarthritis of hip
3. Postoperative
blood loss anemia
4. Hyperkalemia
5. Dehydration –
resolved
6. Ascites in
alcoholic liver cirrhosis
7.
Hyperammonemia
PROCEDURE PERFORMED:
1.
Hemiarthroplasty of right hip
2. Transfusion
of RPBC – 2 units
3. Paracentesis
HOSPITAL COURSE: The patient
was admitted to the hospital for bed rest, hydration, monitoring of blood
pressure and pain medication. The orthopedic surgeon examined the patient and
concurred with diagnosis of femoral neck fracture of the right hip. Performed a
hemiarthroplasty and found an additional fracture of the greater trochanter –
patient tolerated the procedure well. The patient had significant pain after
the surgery and experienced severe blood loss anemia following surgery.
Transfusion of packed cells was given and patient improved. Blood pressure
fluctuated slightly and was controlled well with medication.
On postoperative day two, patient
underwent paracentesis for removal of 2.5 liters of ascites. Postoperative
course was further complicated by the rise in ammonia. This came down with
Lactulose.
Patient was discharged to the subacute
unit for physical therapy. To be maintained on a low salt diet with moderate
fluid restriction.
HISTORY AND PHYSICAL
REASON FOR ADMISSION: Fracture of
right hip
HISTORY OF PRESENT ILLNESS: A 84
year-old-female was walking down the stairs at home when she tripped and fell,
landing on her right side. She believed she broke her hip. Unable to walk and
in severe pain she called her family and they brought her to the hospital.
Examination and x-ray determined a right
hip fracture of the femoral neck with severe osteoarthritis of the same hip.
PAST MEDICAL HISTORY: Significant
for long standing alcoholic liver disease with cirrhosis and ascites. And he
was found to have massive ascites.
SOCIAL HISTORY: Lives alone
with her many cats.
REVIEW OF SYSTEMS: Massive
ascites, liver spans about 2-3 fingers below costal margin and is firm.
PHYSCIAL EXAMINATION: Well-developed
female in considerable distress due to fall. Blood pressure 180/110, pulse 88,
marked muscle wasting.
IMPRESSION:
1. Femoral neck
fracture of right hip secondary to fall at home
2. Dehydration
3. Chronic
cirrhosis
PROGRESS
NOTES
DAY 1 – Fracture of right femoral neck
Postoperative anemia due to blood loss –
transfusion given
Pain – severe
Complete bed rest
DAY 2 – Postoperative care given
Transfusion given
Paracentesis performed
Elevated ammonia level
DAY 3 – Pain in right hip, ‘it feels
too heavy’
Lungs clear
CVS – RRR
Abdomen soft – stools normal
Edema of ankle
Hyperkalemia
DAY 4 – Pain is much better
Compression stockings in place
Anemia stable
Ammonia level within normal limits, abdomen
less tense
DAY 5 – Discharge to subacute unit for
physical therapy
OPERATIVE REPORT
NAME OF OPERATION:
Hemiarthroplasty of right hip
DESCRIPTION OF PROCEDURE: An incision
was made centered over the greater trochanter, carried down to the skin,
subcutaneous tissue, fascia lata, and incised in line with the femur. Following
this, the posterior aspect of the hip is exposed and the short external
rotators are dissected sharply from the proximal femur, and the piriformis is
also incised and saved for later repair. Incision retractor is placed.
Following this, the fracture is identified and the femoral head is delivered
from the acetabulum after opening the capsule in a T fashion.
At this point, the attention was turned
to the fracture and the fracture was somewhat lower than originally expected
and the attempt was made to broach the femur for the hemiarthroplasty. It was
noted that there was an additional fracture, which was present on the lateral
aspect of the trochanter and this later was significant to the point where it
was felt that it required cable fixation. At this point the greater trochanter
was reducted and a trochanteric claw is utilized to grasp the trochanter and
this is affixed with 2 cables. A 3rd cable is placed over the main
fracture. Satisfactory fixation was accomplished.
At this point, the leg was rolled 90
degrees, the foot was raised 90 degrees to the floor and the broaching was done
utilizing a 10 Biomet fracture stem and the broach was positioned
appropriately. At this point, the cement was mixed and the cement was passed
into the proximal femur and the 10 Biomet fracture stem was inserted,
approximately 6-7 degrees of femoral anteversion. The standard was perhaps too
tight and a –3 was placed and the hip was stable with flexion and internal
rotation. Following this the hip is prepared and the cement is dried and the –3
head is placed and the biopolar is assembled and a 47 outer bearing is placed.
The hip is located and again there is good stability. The capsule is repaired
utilizing #0 Vicryl. The piriformis is repaired utilizing #1 Vicryl. The fascia
lata is closed utilizing a running double #1 Vicryl. The subcutaneous tissue is
closed, the deep tissue with 0 Vicryl, the more subcutaneous tissue with 2-0
Vicryl and the skin with skin clips. Hemovac was placed in the depths of the
wound and the soft compression dressing was applied. The patient was placed in
an abduction pillow and rolled supine and then was awakened and taken to the
recovery room.
Replacement was 2 units of packed red
blood cells. Additional 2 units are available. The patient will have a repeat
hemoglobin and hematocrit in the recovery room. The patient was given Ancef at
the start of the case and at the end of the case and this will be continued
postoperatively.
