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CPT codes: ICD-10-CM codes: ICD-10-PCS codes: Rationale: LOCATION: Inpatient, Hospital PATIENT: Edith Smith PHYSICIAN: Mohomad Almaz, M.D. CHIEF COMPLAINT: Left thigh pain. PRESENT ILLNESS: This patient is a 54-year-old woman with chronic obstructive pulmonary disease (COPD) who is steroid-dependent, and on home oxygen. She apparently fell at home today when she tripped and twisted her left leg. She was seen in the Emergency Room, where x-rays revealed a supracondylar fracture of her left femur and she was referred for treatment because of this. Patient is alert and cooperative. She is afebrile. She complains of pain in her left leg just above her left knee, and denied pain elsewhere. She told me that she normally was able to get around fairly well at home. She does have a long history of COPD. She is on prednisone 20 mg daily. According to some of the past medical records, she has secondary polycythemia. She apparently was a chronic smoker. She has severe pulmonary hypertension with congestive heart failure. She has had a cholecystectomy and appendectomy. She had a left humeral neck fracture in the past. PHYSICAL EXAMINATION today found that she is an alert and cooperative Native American female, who arrived in the Emergency Room lying on a cart with the left leg in a long leg splint applied by the ambulance crew and secured with Velcro straps. She appeared to be fairly comfortable. She was able to easily answer questions, and moved her upper extremities well and moved her right leg well. She appeared to be aware of her surroundings and oriented to place and time. Examination of her left leg found that the foot was externally rotated. She was, however, able to dorsiflex and plantar flex her foot and toes. The dorsalis pedis pulse was easily palpable. There were no lacerations or abrasions about the left thigh. She had pain just above her left knee with any movement of the leg, however. X-RAYS of her left femur found that she does have a comminuted displaced supracondylar fracture. The knee is seen on these views and the joint spaces appear to be fairly well preserved, although there is some calcification along the medial side of her knee joint. IMPRESSION: 1. Comminuted displaced supracondylar fracture, left femur, closed. 2. History of chronic obstructive pulmonary disease. 3. Severe pulmonary hypertension with congestive heart failure. 4. Status post cholecystectomy and appendectomy. 5. Secondary polycythemia. 6. Status post left humeral neck fracture. RECOMMENDATIONS: I have thoroughly discussed this left femur problem with her. I have recommended an open reduction internal fixation using a supracondylar plate. I have discussed the risks involved with her in detail, as she is a rather poor surgical risk. She understands that there is certainly a chance for an infection and there is certainly a chance for a nonunion or a mal-union. Thrombophlebitis is a possibility. She may have a stroke or a heart attack. It is possible that she may have difficulty getting off a respirator if she has a general anesthetic. We have discussed all these and other possible risks. She would like to go ahead with the surgery. I will ask Dr. Frank Gaul to see her preoperatively; however, I have not been able to contact him yet. If he feels that she is an acceptable candidate for surgery, we will proceed tonight; however, if he desires more time for workup, we will do this perhaps tomorrow if he agrees. Her questions have been answered and she understands that there are very significant risks involved with this. CPT codes: ICD-10-CM codes: ICD-10-PCS codes: Rationale:

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