bharathiT
Guru
Assessment
1. Infected abrasion of hand (S60.519A,L08.9)
2. Contusion of hand, left (S60.222A)
Plan
Medications
1. Start: Sulfamethoxazole-Trimethoprim 800-160 MG Oral Tablet; TAKE 1 TABLET TWICE
DAILY UNTIL FINISHED
3. XR HAND-LEFT; Status:Complete
1-Wound debrided, cleaned and bandaged during visit. Rocephin shot during visit. Start oral antibiotics right away.
2- Tylenol for pain. Elevate at rest. Activity restrict
Follow up in 2 days for recheck. Seek more immediate attention if symptoms worsen or change.
Chief Complaint*:
pt complains of L hand injury, pt stated was in tuesday, pt went to ER, and had some stitches and pt think is infected
Patient rates their health as: good.
HPI: the patient denies abdominal pain. no fever no headache no neck pain no weakness
Pt crashed on bike 5 days ago-treated at ER for hand laceration. Past 24 h-despite taking keflex-increased redness. Left hand painful and states -no x-ray.
Redness extending into forearm-left side.
ICD -infected abrasion of hand (S60.519) coded as Initial or subsequent encounter?
1. Infected abrasion of hand (S60.519A,L08.9)
2. Contusion of hand, left (S60.222A)
Plan
Medications
1. Start: Sulfamethoxazole-Trimethoprim 800-160 MG Oral Tablet; TAKE 1 TABLET TWICE
DAILY UNTIL FINISHED
3. XR HAND-LEFT; Status:Complete
1-Wound debrided, cleaned and bandaged during visit. Rocephin shot during visit. Start oral antibiotics right away.
2- Tylenol for pain. Elevate at rest. Activity restrict
Follow up in 2 days for recheck. Seek more immediate attention if symptoms worsen or change.
Chief Complaint*:
pt complains of L hand injury, pt stated was in tuesday, pt went to ER, and had some stitches and pt think is infected
Patient rates their health as: good.
HPI: the patient denies abdominal pain. no fever no headache no neck pain no weakness
Pt crashed on bike 5 days ago-treated at ER for hand laceration. Past 24 h-despite taking keflex-increased redness. Left hand painful and states -no x-ray.
Redness extending into forearm-left side.
ICD -infected abrasion of hand (S60.519) coded as Initial or subsequent encounter?