Location: Hospital PROGRESS NOTE

question 35

Short Answer

Location: Hospital
PROGRESS NOTE
The patient is seen today. She has been transferred from the ICU to the floor. She has essentially stabilized. Again, she is having some type of seizure activity.
PHYSICAL EXAMINATION: Her vitals overall are fairly well stabilized. Her postoperative dressings are in place. She did have a significantly elevated INR so
the dressings have been kept in place to minimize the risk of bleeding. She was sleeping when I saw her so I did not wake her. Her toes are pink and warm. Calves are soft.
IMPRESSION: Seizure, status post left hip bipolar hemiarthroplasty.
PLAN: I will continue to follow. From my standpoint, she can mobilize and weight bear as tolerated on the left side. We will change her dressings and place TED hose on the left. We will continue to follow her INR and hemoglobin. Of note, she has been made code status II.
CPT Code: ____________________

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