Date of Service: 2018-01-26Visit Type: WoundTransition of Care: No transition occurred.Encounter Summary Details: Progress Note History History Of Present Illness: Neoplasm Rt breast POA Medication List: Metoprolol 25 mg p.o. daily, metformin 500 mg twice daily, simvastatin 40 mg daily, lisinopril 1 tab daily, Coumadin 2.
5 mg daily, magnesium oxide 400 mg twice daily, nystatin topical powder 3 times a day of the right breast, Tylenol as needed, Ultram 50 mg every 8 as needed, Past Medical History: History of chronic atrial fibrillation history of type 2 diabetes history of hypertension history of hyperlipidemia history of previous CVA Past Surgical History: Patient had previous surgery on her right knee Social History: The patient has no history of tobacco, alcohol, or illicit drug use. Family History: Noncontributory Review Of Systems Respiratory: No upper respiratory infections, dyspnea, cough or wheezing. Musculoskeletal: Ambulatory. Skin/Breast: No rashes or skin breakdown. Physical Exam General: This patient is well developed and in no acute distress.
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Arterial: Patient has decreased pedal pulses bilaterally. Chest: No chest deformity. Skin: Wound Etiology: Neoplasm Wound Location: Rt breast Stage: n/a Duration: POA Wound Size: 2.5×6.5×0.
2 undermining/ Tunelling: none Exudate: moderate serrous Odor: none Wound Base: 50 % granulation tissue , 50 % epithelial tissue Periwound : No mcaration note Wound Edge: irregular, cauliflower like in appearance Wound Progress:Stable Diagnosis and Assessment Assessment: CPT Codes: 99309 ICD Codes: 879.0 / S21.001A: Open wound of right breast Plan: 1. Cleanse wound with N/saline daily 2..
Apply Silver Alginate to wound cover with gauze 3. Plan discussed with nursing staff ***** Document e-signed by Clare Scott, APN on Jan 26 2018 1:32PM EST ***** Genesis Physician Services, LLCProvider: Clare Scott, APNSigned Date: 2018-01-26 13:32:15Created By: Clare ScottAddendum details: