cchilva
New
One of my Dr's did a consult IP. Here is the report
Reason for Consult: Redness on the right thigh
History of Present Illness: This 66 year old Caucasion male was seen for evaluation of an extremely tender, erythematous and painful plaque-like eruption by history located on the dorsum of his right thigh. This was a couple of days ago and, when seen today, most of this condition has spontaneously resolved. He relates the erythema is virtually back to normal. The swelling and tenderness have dissipated and the pain is negligible. His feeling was that this may have been triggered by compression, laying on it, that kind of a physical constriction and, at this point, I have no way to help decide the etiology either way.
What we have decided is to hold off anything and just see if Mother Nature will continue to provide a spontaneous resolution to this problem.
Past Medical History: We have reviewed his past history and it is significant for some surgeries on the hemorrhoidectomy, polypectomy. He is currently evaluated for some abdominal problems including urinary retention.
So I feel that perhaps just careful monitoring seems to be the most prudent responds and so, if there is a resurgence of his condition and a recurrence of it, I would be most happy to return and re-evaluate and see what the appropriate response should be.
Thank you very much for allowing me to consult and participate in the care of this patient.
Does anyone see a consult in this report? I am working on learning how to code E/M and would appreciate any input on this.
Reason for Consult: Redness on the right thigh
History of Present Illness: This 66 year old Caucasion male was seen for evaluation of an extremely tender, erythematous and painful plaque-like eruption by history located on the dorsum of his right thigh. This was a couple of days ago and, when seen today, most of this condition has spontaneously resolved. He relates the erythema is virtually back to normal. The swelling and tenderness have dissipated and the pain is negligible. His feeling was that this may have been triggered by compression, laying on it, that kind of a physical constriction and, at this point, I have no way to help decide the etiology either way.
What we have decided is to hold off anything and just see if Mother Nature will continue to provide a spontaneous resolution to this problem.
Past Medical History: We have reviewed his past history and it is significant for some surgeries on the hemorrhoidectomy, polypectomy. He is currently evaluated for some abdominal problems including urinary retention.
So I feel that perhaps just careful monitoring seems to be the most prudent responds and so, if there is a resurgence of his condition and a recurrence of it, I would be most happy to return and re-evaluate and see what the appropriate response should be.
Thank you very much for allowing me to consult and participate in the care of this patient.
Does anyone see a consult in this report? I am working on learning how to code E/M and would appreciate any input on this.