PATIENT: O’DAY, SHANNON ACCOUNT/EHR #: ODAYSH001 DATE: 12/09/23 Attending Physician: Gena Reynoldo, MD This is a 7-year-old female who presents with a chief complaint of left wrist pain. She was rollerblading with several friends and was accidentally pushed from behind. She fell forward with outstretched, pronated arms. She denies hitting her head, loss of consciousness, vomiting, and abdominal pain. EXAM: VS T37.0, P105, R20, BP 117/75. She is comfortable, alert, and appears to be in no distress. Mild abrasions are noted on her left knee and palmar surfaces of both hands. No obvious puncture wounds are present. She has mild discomfort upon palpation of her left knee, but she is able to walk, stand, and jump without difficulty or discomfort. Her right wrist is normal, but tenderness is elicited upon palpation of her left distal radius. Slight wrist swelling is noted, but no angular deformity is present. The remainder of her exam is unremarkable. Radiographs reveal a nondisplaced radial shaft fracture without angulation. She is placed in a forearm sugar tong splint, and her mother is given instructions to follow up in 3 weeks. LIST DIAGNOSIS CODES (PRIMARY, AND EXTERNAL CAUSES (1 V CODE AND 2 Y CODES) ) AND CPT PROCEDURE CODE(S) WITH LATERALITY MODIFIER
[Verified Answer]: PATIENT: O’DAY, SHANNON ACCOUNT/EHR #:…
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