Date of Service: 2018-01-26
Visit Type: Wound
Transition 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.
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, LLC
Provider: Clare Scott, APN
Signed Date: 2018-01-26 13:32:15
Created By: Clare Scott
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