Documentation Guidelines Evaluation Explained for Students (Easy Guide)
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Original Question
Use the 2021 Documentation Guidelines for Evaluation and Management Initial Office Visit CHIEF COMPLAINT: Rash on right calf with swelling and tenderness HISTORY OF PRESENT ILLNESS: The patient joined a gym 1 month ago and noticed the onset of the rash 1 week ago prior to this visit. The rash began with redness and progressed to small blisters. He had a fever since yesterday with chills, malaise and dizzy sensation. PAST MEDICAL HISTORY: The patient does not smoke. No prior operations. REVIEW OF SYSTEMS: There is itching between the 1st and 2nd digits of the right foot for approximately 1 month. PERRLA: No difficulty breathing or swallowing. Denies chest pain, nausea or vomiting. NO KNOWN ALLERGIES PHYSICAL EXAMINATION: GENERAL: This is a well-nourished, well-developed 22-year old white mail who is pleasant and cooperative. VITAL SIGNS: Pulse 100, regular. Temperature: 102 F HEENT: Normocephalic. Eyes: EOM’S intact. Ears: Tympanic membrane is normal to inspection. NECK: Supple, no adenopathy. CHEST: Heart and lungs normal to percussion and auscultation ABDOMEN: There is a right inguinal adenopathy. Abdomen is soft without evidence of organomegaly RECTAL: The prostate is normal in size. No blood is seen on the examining finger. Stool guaiac negative EXTREMITIES: There is a large, well demarcated, shiny, red, edematous, tender rash covering most of the lateral aspect of the right leg with peripheral tenderness. Vesicles are present. in addition, there is an intertriginous rash between the 1st and 2nd digits of the right foot. NEUROLOGIC: Except for the tenderness in the right leg, no deficits are demonstrated. DTRs are normoreflexive. IMPRESSION 1. Febrile vesicular rash, right leg, most likely erysipelas 2 Intertriginous fungal infection of the foot PLAN Prescribe Pen Vee K 250 mg p.o. q.i.d. on an outpatient basis for 14 days. Cold packs for pain. Aspirin 600 mg p.o.q. 3h. p.r.n. for pain. ICD-10- CM :___________ ICD-10-CM: ____________ E/M: (EVALUATION & MANAGEMENT CODE) ___________
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