Patient was out hiking in the forest with her dog when she accidentally tripped over a rock. When she stood up, she seemed okay, according to her and decided to return to her car. By the time she got to her vehicle, she noted pain and swelling in her left knee. At that point, she had difficulty bending the knee and decided to drive herself to the ED for treatment. Exam showed she had sprained her
lateral collateral ligament. She was put in a knee immobilizer and told to follow RICE—rest, ice, compression, and elevation. She was also advised to contact her PCP tomorrow. The patient declined a prescription for pain medication.
Dx: Sprained knee
First-listed diagnosis: ________
Secondary diagnoses: ________
Fill in the blank with correct word.
First-listed diagnosis: ________
Answer: Sprained lateral collateral ligament – left knee – S83.422A
Secondary diagnoses: ________
Answer: Tripping over a rock – with fall – W18.09XA; place of occurrence – forest – Y92.821; activity – hiking – Y93.01
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