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Emergency Department Record
Chief Complaint: Right arm laceration
History of Present Illness:
This 24-year-old man presents here after attempting to punch out a window in his garage door with his elbow in an attempt to enter his own house.
Medications: None
Allergies: Keflex
Last Known Tetanus: Unknown
Review of Systems: No shoulder pain, no wrist pain. Complains of multiple lacerations of the forearm.
Extremities: Right elbow and right forearm reveal multiple lacerations in various lengths from proximal and working distally. Over the area of the olecranon, there is noted to be a 3-cm superficial laceration. There is also noted to be several simple lacerations distally: approximately four measuring 1 cm and three others measuring 2 cm each. There is noted to be a 5-cm laceration involving deeper layers of skin.
Procedure: After adequate anesthesia was obtained with local infiltration of all lacerations with 1% lidocaine with epinephrine, the wounds were explored. No foreign bodies were appreciated. Each wound was vigorously irrigated and draped individually in a sterile fashion. Initially, the 3-cm laceration along the area of the olecranon was closed with two interrupted sutures of 4-0 Ethilon. The remaining smaller wounds were closed with simple sutures. The 5-cm laceration required closing with 3-0 Vicryl for the subcutaneous layer and 4-0 Vicryl to close the skin. Wound edges were painted with Benzoin and Steri-Strips applied. The patient tolerated the procedure well.
Assign only CPT surgical codes (no E/M codes) and append any applicable modifiers.
***This question requires 2 codes.
SCIENCE
HEALTH SCIENCE
NURSING
