Bernadette10
Guru
This patient was seen a week ago and started on antibiotics. Now comes back with abscess worsening. I think it should be 10060 only, or does this show enough MDM for re-evaluation and decision to I&D for 99213-25? Also I thought 10060, not 10061. Is that correct? Thanks for any advice.
Patient presents for reevaluation of abscess to upper back. Patient is currently on Bactrim since 2/17/2022. He states abscess has gotten larger. He has been afebrile.
Review of Systems
Constitutional: Negative for appetite change, fatigue and fever.
HENT: Negative for congestion, rhinorrhea and sore throat.
Eyes: Negative for discharge and redness.
Respiratory: Negative for cough, shortness of breath and wheezing.
Cardiovascular: Negative for chest pain and palpitations.
Gastrointestinal: Negative for abdominal pain, diarrhea, nausea and vomiting.
Genitourinary: Negative for dysuria and frequency.
Musculoskeletal: Negative for arthralgias and myalgias.
Skin: Positive for wound. Negative for rash.
Social History
Tobacco Use
Smoking status: Current Every Day Smoker
BP 132/88 (BP Location: Left arm, Patient Position: Sitting) | Pulse 83 | Resp 18 | Ht 170.2 cm (67") | Wt 67.6 kg (149 lb) | SpO2 96% Comment: RA | BMI 23.34 kg/m²
Physical Exam
Constitutional:
Appearance: Normal appearance. He is not ill-appearing or toxic-appearing.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: Tympanic membrane normal.
Left Ear: Tympanic membrane normal.
Nose: Nose normal.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear.
Eyes:
Extraocular Movements: Extraocular movements intact.
Conjunctiva/sclera: Conjunctivae normal.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds. No wheezing.
Abdominal:
General: Bowel sounds are normal.
Palpations: Abdomen is soft.
Musculoskeletal:
General: Normal range of motion.
Skin:
General: Skin is warm and dry.
Findings: Lesion (Indurated abscess to left upper back with fluctuant center) present. No rash.
Neurological:
General: No focal deficit present.
Mental Status: He is alert and oriented to person, place, and time.
Psychiatric:
Mood and Affect: Mood normal.
Behavior: Behavior normal.
Thought Content: Thought content normal.
Diagnoses and all orders for this visit:
Abscess of back
Not improving with oral antibiotics
Will have packing removed by hospital nurses
Procedure Note
Incision and Drainage of Abscess
After informed consent obtained, area was cleansed with chlorhexidine and draped in a sterile manner. The site was anesthetized with 1 % lidocaine with epinephrine. A linear incision was made with a # 11 blade and the purulent material expressed. The abscess was explored thoroughly and loculations broken up. Area was copiously irrigated with normal saline. Wound was packed with Iodoform packing and dressing applied. Hemostasis was achieved. Patient tolerated procedure well without complication. Wound care instructions given.
Return for Follow up if symptoms not improving.
Patient presents for reevaluation of abscess to upper back. Patient is currently on Bactrim since 2/17/2022. He states abscess has gotten larger. He has been afebrile.
Review of Systems
Constitutional: Negative for appetite change, fatigue and fever.
HENT: Negative for congestion, rhinorrhea and sore throat.
Eyes: Negative for discharge and redness.
Respiratory: Negative for cough, shortness of breath and wheezing.
Cardiovascular: Negative for chest pain and palpitations.
Gastrointestinal: Negative for abdominal pain, diarrhea, nausea and vomiting.
Genitourinary: Negative for dysuria and frequency.
Musculoskeletal: Negative for arthralgias and myalgias.
Skin: Positive for wound. Negative for rash.
Social History
Tobacco Use
Smoking status: Current Every Day Smoker
BP 132/88 (BP Location: Left arm, Patient Position: Sitting) | Pulse 83 | Resp 18 | Ht 170.2 cm (67") | Wt 67.6 kg (149 lb) | SpO2 96% Comment: RA | BMI 23.34 kg/m²
Physical Exam
Constitutional:
Appearance: Normal appearance. He is not ill-appearing or toxic-appearing.
HENT:
Head: Normocephalic and atraumatic.
Right Ear: Tympanic membrane normal.
Left Ear: Tympanic membrane normal.
Nose: Nose normal.
Mouth/Throat:
Mouth: Mucous membranes are moist.
Pharynx: Oropharynx is clear.
Eyes:
Extraocular Movements: Extraocular movements intact.
Conjunctiva/sclera: Conjunctivae normal.
Cardiovascular:
Rate and Rhythm: Normal rate and regular rhythm.
Heart sounds: Normal heart sounds.
Pulmonary:
Effort: Pulmonary effort is normal.
Breath sounds: Normal breath sounds. No wheezing.
Abdominal:
General: Bowel sounds are normal.
Palpations: Abdomen is soft.
Musculoskeletal:
General: Normal range of motion.
Skin:
General: Skin is warm and dry.
Findings: Lesion (Indurated abscess to left upper back with fluctuant center) present. No rash.
Neurological:
General: No focal deficit present.
Mental Status: He is alert and oriented to person, place, and time.
Psychiatric:
Mood and Affect: Mood normal.
Behavior: Behavior normal.
Thought Content: Thought content normal.
Diagnoses and all orders for this visit:
Abscess of back
Not improving with oral antibiotics
Will have packing removed by hospital nurses
Procedure Note
Incision and Drainage of Abscess
After informed consent obtained, area was cleansed with chlorhexidine and draped in a sterile manner. The site was anesthetized with 1 % lidocaine with epinephrine. A linear incision was made with a # 11 blade and the purulent material expressed. The abscess was explored thoroughly and loculations broken up. Area was copiously irrigated with normal saline. Wound was packed with Iodoform packing and dressing applied. Hemostasis was achieved. Patient tolerated procedure well without complication. Wound care instructions given.
Return for Follow up if symptoms not improving.