'Click to return to E/M University Home page, EM Coding Education
CLINICAL EXAMPLE 99221
 

 
A patient with uncomplicated right foot cellulitis

CC: “My right foot hurts”

Reason for consult : Evaluation and management of possible new onset CHF  

Requesting physician
:
John Doe, MD

HPI :The patient is a 45 year old homeless man who cut his right foot on a piece of glass about three days ago.  He has noted increasing pain and swelling as well as stiffness in his right foot over the past 24 hours.  The pain is described as a “burning” sensation.

ROS

Constitutional - Positive for subjective fevers and chills
Musculoskeleta - Negative for joint pain or stiffness in his right lower extremity
Pulmonary - Positive for intermittent non-productive cough

Pertinent PFSH is remarkable for ongoing alcohol and tobacco abuse

Physical Exam

General: Unkempt white male who looks older than stated age; NAD
Vitals: 120/80, 72, 100.0
Eyes: anicteric sclerae with moist conjunctivae
Oropharynx: Clear with MMM and no erythema; poor dentition with multiple caries and missing. teeth
Lungs: CTA .   CV: RRR without MRGs .  Abdomen: Soft, non-tender, no HSM
Extremities: Right foot shows swelling from the ankle to the knee; no pain to palpation in either
joint; FROM; no extremity edema on the left

Labs: WBC 17,000 HGB 11.5

Assessment
  1. Right lower extremity cellulitis
Plan
  1. Admit for three days of intravenous antibiotics
  2. Alcohol withdrawal protocol

For a detailed breakdown of this note with tips and advice see   99221 E/M Insight

Tell A Friend!  

Home   |   Contact Us   |   Privacy Policy
Copyright © 2003 -  EM University. Web Design: Abacus Web Services
 
Click to return to E/M University Home page, EM Coding Education