Diagnosis: Right ankle fracture
Treatment: Inpatient stay

Summary:
The patient is a male with a history of hypertension. He sustained an injury to his right ankle. He was diagnosed with a fracture and underwent open reduction internal fixation and deltoid ligament repair. He was admitted to hospital and underwent surgery. His post-surgical course was non-complicated.

The patient required an immediate closed reduction. He received high dose parenteral narcotics. He required open reduction internal fixation to his ankle. The procedure was complex and extensive. The operative report was significant for attention to several structures. He underwent fixation to his medial malleolus, plate fixation to the distal fibula, repair of syndesmosis and repair to deltoid ligament.

This operation would be expected to be painful and require parenteral narcotics post-surgery. The injury, type of treatment provided and post-surgical course support necessity of services provided, i.e., inpatient admission and all length of stay.

These services could not have been provided in outpatient facility.