ASSIGNMENT: EPISODIC VISIT: DERMATOLOGY FOCUSED NOTE
ASSIGNMENT: EPISODIC VISIT: DERMATOLOGY FOCUSED NOTE
Case Study:
16 year-old male presents with mom to establish and complains of R foot pain. R hallux has swelling, puss, discharge, and 8/10 pain for the past year. Was seen in ED last week and given Keflex PO and saw podiatrist last thursday who removed the toe nail.
ICD 10 Codes/CPT Codes: L03.031
[elementor-template id="165244"](Cellulitis of right toe) F33.2
(Ingrowing nail) H61.23
Treatment Plan:
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– Labs completed in the office today will call with results. CBC, BMP, A1C, Lipid panel
Notes: Call the office if symptoms do not improve or worsen. Call 911 anytime you think you may need emergency care.
– Continue taking ABT from ED visit, administered Ceftriaxone IM. Patient was advised if symptoms do not improve or worsen in the next 48-72 hours to call the office and in the event of an emergency go to the ER.
– Order for R hallux Xray to rule out osteomyelitis – New order for podiatry consult.
Assignment
Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 code for the diagnosis. What was your primary diagnosis and why?
Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?
You can make up pt past medical history, social history, medication list, etc.
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