How to Answer Chief Complaint Follow Questions (Complete Guide)

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Chief Complaint: Follow up for left ankleHistory of Present Illness: Mrs. Smith presents to our practice initially today as a new patient with a h/o varicose veins, goiter, obesity, dyspepsia, and right knee pain. She was noted to have ulcer medial left ankle due to stasis and was started on Bactrim and is taking as prescribed. She had x-ray done and was negative. She notes pain is improving but ulcer and increasing and has some drainage from area. No fever or chills. MRI of left ankle results show cellulitis but no osteomyelitis. Medications: Aspirin 325mg, Ciprofloxacin 500mg, Multivitamin, Omeprazole 20mg, Sulfamethoxazole-TMP 800-160mg, Topiramate 25mg, Tramadol 50mg Review of Systems: Constitutional: negative. Head and Face: negative. Eyes: negative. ENT: negative. Cardiovascular: negative. Respiratory: negative. Gastrointestinal: no abdominal pain, no abdominal bloating, no abdominal cramps, no reflux, no nausea, no vomiting, no diarrhea, able to pass flatus, no constipation, no bright red blood per rectum, no melena and no hematemesis. Genitourinary: no dysuria, no urinary frequency, no flank pain, no suprapubic pain, no pelvic pain, no dark urine and no hematuria. Musculoskeletal: joint swelling, joint stiffness and pain in other joints, but no diffuse joint pain, no generalized muscle aches, no back pain and no back muscle spasm. Integumentary: erythema, edema and skin ulcer, but no skin lesions, no skin wound, no itching, no painful skin area with a rash or sore and no mouth sores. Breasts: negative. Neurological: negative. Psychiatric: negative. Endocrine: negative. Hematologic and Lymphatic: negative. Surgical History: History of Cesarean Section History of Endovenous Ablation of Incompetent Vein History of Foot Surgery Family History: Family history of cerebrovascular accident Family history of diabetes mellitus FH: heart disease Family history of cancer Family history of cancer Social History: Caffeine use Former smoker Former smoker Allergies: NKDA Vitals Temperature: 98.6 Heart Rate: 17 Respiration: 130 BP: 80 Physical Exam: General appearance: Normal. Head: Normocephalic HEENT: Normal CV: Regular rhythm and rate Respiratory: Clear to A&P Skin and subcutaneous tissue: Abnormal. Ulcerated lesion with surrounding erythema left malleolus with mild tenderness to touch. No warmth and minimal eschar. Neuro: Intact Psychiatric Mood and affect: Normal. Results/Data DATE/TIME: November 22, 20XX EXAM: MRI Left ankle. CLINICAL HISTORY: Left ankle cellulitis, skin infection, ulcer. TECHNIQUE: Multiplanar multiecho sequence imaging of the Left ankle was carried out with the aid of 1.5 Tesla field strength magnetic resonance imaging before and following intravenous administration of 9 ml of Gadavist. COMPARISON STUDIES: Left ankle radiograph report one year ago FINDINGS:Bones: There is no acute fracture or subluxation. Subchondral cystic change with marginal osteophytes and edema is present at the mid foot involving the middle cuneiform and lateral cuneiform metatarsal articulations. The remaining marrow signal is normal. There are no findings to suggest osteomyelitis. Tendons: The Achilles tendon is normal. The peroneus longus and peroneus brevis tendons are intact and appear normal. There is a small amount of fluid within the tendon sheath of the tibial is posterior tendon, the tendon itself is intact. The flexor digitorum longus and flexor hallucis long us tendons are normal. Ligaments: The anterior and posterior tibiofibular, the anterior and, posterior talofibular, and the calcaneofibular ligaments are intact and normal. The superficial and deep fibers of the deltoid are intact and normal. The spring ligament is normal. Other: There is no joint effusion within the ankle or subtalar joint. There is ill defined edema within Kager’s fat pad. There is skin thickening with subcutaneous edema at the posterior medial aspect of the ankle with enhancement in the region subjacent to the patient’s wound most consistent with cellulitis. IMPRESSION: Wound at the posterior medial aspect of the left ankle with subcutaneous edema and enhancement. Reactive cellulitis. There are no findings to suggest osteomyelitis. Osteoarthritic changes involving the mid Lisfranc joint of left foot. Mild reactive tenosynovitis of the tibia is posterior tendon. *** THIS IS AN ELECTRONICALLY VERIFIED REPORT*** 11-22-20XX Steven Grimes, MD Assessment/Plan: Stasis ulcer of ankle, left Cellulitis, left ankle with bone involvement Ankle pain, left Right knee pain Dyspepsia what is the correct ICD-10-CM codes

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