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CLINICAL EXAMPLE 99242
 

 
42 year old male referred to allergist to be evaluated for allergic reaction to spider bite

Reason for consult : Evaluation and management of insect bite     

Requesting physician : John Doe, MD

HPI :The patient states he was cleaning out a shed in his back yard yesterday when he was bitten by a brown spider on the left thumb.  The bite was initially described as “really, really painful”, but has since improved.  The patient noted worsening redness and swelling of the thumb last evening.  He is referred for evaluation to rule out possible allergic reaction to the venom.

ROS   
Cardiovascular - Negative for palpitations, racing heartbeat, chest pain
Pulmonary - Negative for wheezing, cough or dyspnea

Physical Exam

General: No acute distress, conversant, well nourished male
Vitals: 120/80, 98.6, 72
Lungs: CTA
CV: RRR, no MRGs
Extremities: No peripheral edema or digital cyanosis
Skin: left thumb has a 1 mm punctate lesion with an erythematous base and minimal induration;
there is mild soft tissue swelling

Assessment
  1. Simple spider bite
  2. Mild localized inflammation, with no evidence of systemic allergic reaction to venom
Plan
  1. Superficial dressing placed
  2. Routine wound care instructions provided
  3. Return visit if worsening swelling or redness
  4. Will send a copy of this note to Dr. Doe

For a detailed breakdown of this note with tips and advice see  99242 E/M Insight

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