OFFICE VISIT
S: This new patient got into a fight a week ago, smacked a person and had his left third knuckle cut with a tooth. This has been red and swollen for the last couple of days. Today it is much redder and much more swollen. lt is very tender.
PAST MEDICAL HISTORY: No medical problems.
MEDICATIONS: NONE.
ALLERGIES: NONE.
O: VITAL SIGNS: As noted.
HEENT: Unremarkable.
LUNGS: Clear.
HEART: Regular rate and rhythm.
EXTREMETIES: The left knuckle over the metacarpophalangeal joint is erythematous approximately 7 cm patch with a little bit of swelling right over the joint. It is very tender to touch.
A: Cellulitis of the left hand.
P: We will put him on Cephalexin 500 two pills three times a day for 10 days.
We gave him Lortab 7.5 very 4-6 hours as needed for pain. He is to keep heat on this and follow up in 48 hours. If he is getting worse, he should come back sooner.
ICD-9-CM diagnosis code(s): _____________________
ICD-10-CM diagnosis code(s): _____________________
CPT code(s) with modifier, if applicable: _____________________
Technique of Direct Fist Percussion: Left Kidney
Buccal Mucosa Conditions, Left Parotitis
Direct Fist Percussion of Left Kidney
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