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26.02.2021 •
Medicine
1. Emergency Room:
Patient Name: Charles Teal
Date of visit: 1/4/2019
Age: 50
Sex: Male
Insurance: HMO
Emergency Room Visit:
Date: 1/4/2019
Chief complaint: Cyst on groin area for several days
History of present illness: Patient complains of a tender swollen spot in the perirectal region. This has occurred for several days. It is painful and it is getting worse as time progresses.
Past medical history: negative for diabetes or hypertension
Medications: none
Allergies: ASA
Social history: patient smokes one packet per day
Review of symptoms: All negative
Physical Examination:
General: Patient is alert & orientated x 3. Patient is in moderate distress.
Vitals: BP: 130/80; P:111; R:21; T:100
Skin: There is a fluctuant abscess in the scrotal area, which needs to be drained.
Procedure: Skin was prepped with betadine, and lidocaine 1% was given. The abscess was incised with a #11 knife and a large amount of pus drained. The area was irrigated with saline and packed with gauze.
Impression: Abscess of the scrotal wall
Discharge instruction: patient is to follow up in 3 days for removal of the gauze. Patient is to take Tylenol if needed for pain.
History: Problem-focused
Physical exam: problem-focused
Medical Decision: straight-forward
What is the diagnosis codes & procedure codes?
Diagnosis Code(s):
Procedure Code(s) (CPT):
Solved
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