Procedure – Dsg change, Suture/staple removal

new patient existing patient history provided by patient history provided by family member SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA

CC: wound recheck packing removal wound repacking suture removal staple removal

LOCATION:

HPI: originally seen here originally seen elsewhere 3 days ago 7 days ago 10 days ago taking abx abx not given healing well denies increasing pain/fever/redness/discharge denies motor/sensory/vascular loss

PERTINENT MEDICAL HISTORY: recent hospitalization surgery recent specialty consult recent new/changed medications recent travel sick contact smoker immunosuppression non-contributory none provided

REVIEW OF SYSTEMS: [+] reported [-] not reported
negative except as stated in HPI

CONSTITUTIONAL:

objective fever subjective fever chills
EYES:

change in vision photophobia periorbital swelling pain with EOM
EARS:

pain bleeding tinnitus decreased in hearing
NOSE:

discharge snoring bleeding
MOUTH/THROAT:

bleeding tongue pain/swelling sore throat odynophagia dysphagia hoarseness
NECK:

pain stiffness swelling swollen glands
CV:

chest pain/pressure dyspnea orthopnea ankle swelling ankle discoloration leg cramps
CHEST/RESPIRATORY:

chest tightness pain w/ breathing rib pain cough
GI:

poor appetite nausea vomiting abdominal pain constipation diarrhea
GU:

dysuria hematuria retention oliguria incontinence genital lesions/discharge
NEURO:

dizziness vertigo poor balance abnormality of walk focal weakness blackouts seizures tingling/numbness
PSYCH:

irritability confusion depression anxiety mood swings memory loss insomnia
LYMPH/HEMA:

gland swelling bruising anticoagulation DVT/clotting anemia autoimmune dz h/o cancer

Appearance: well-appearing alert non-toxic normal WOB crying but consolable speaking in full sentences ill-appearing tired-looking short of breath diaphoretic drowsy appears impaired slumped heavy built muscular lean well-nourished frail

Skin: warm, dry grossly intact, no rashes no bruises normal turgor dry tattoos body piercings pallor cyanosis poor turgor diaphoresis rash

Head/Face: normocephalic, atraumatic symmetrical face CN grossly intact

Eyes: clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus visual acuity grossly intact conjunctival injection epiphora conjunctival exudate allergic shiners dennie lines palpebral edema palpebral exudates glasses contacts

Ears: symmetrical & intact auricles bilaterally hearing to conversation intact no mastoid tenderness clear canals without erythema or discharge TMs normal in appearance tragal tenderness swelling of external auditory canal pustule in canal cerumen in canal TM obscured by cerumen HOH hearing aid(s) TM red TM bulging TM perforated TM retracted fluid behind TM tube in TM mastoid tenderness

Nose: nares patent bilaterally septum midline no facial tenderness mucosa pink & moist allergic salute maxillary tenderness frontal tenderness deviated septum mucosal edema clear discharge purulent drainage

Mouth: tongue normal in appearance w/o lesions and with good symmetrical movements moist oral mucosa without lesions upper denture lower denture poor dentition tooth decay single oral ulcer multiple oral ulcers gum swelling

Throat: normal voice no stridor patent pharynx w/o swelling or exudates uvula midline hoarseness inspiratory stridor muffled voice vesicles on soft palate petechiae on soft palate pharyngeal erythema w/o exudates pharyngeal crowding tonsilar enlargement tonsilar erythema tonsilar exudates tonsilar crypts tonsilar pustules

Neck: symmetric with free painless ROM no masses noted no LAD anterior LAD posterior LAD

Chest/Lungs: normal work of breathing, symmetrical chest expansion chest wall atraumatic and non-tender no retractions clear and equal breath sounds bilaterally no axillary or supraclavicular LAD respiratory distress breath sounds decreased bilaterally coughing poor effort expiratory wheezing crackles

CV: regular rhythm no murmurs no ankle edema tachycardia irregular heart rhythm systolic murmur ankle edema varicosities stasis discoloration calf tenderness

Abdomen: normal visual inspection no distension protruding normal bowel sounds soft non-tender guarding diffuse tenderness over entire abdomen w/o RRG direct non-rebound tenderness hypoactive bowel sounds hyperactive bowel sounds not examined

GU: no suprapubic tenderness no CVAT bilaterally normal external genitalia not examined

MSK: no gross deformities, moves all extremities with good ROM for age full weight-bearing normal curvature & ROM in C- & L-spine for patient’s age

Neuro: normal concentration and attention memory grossly intact balance & coordination grossly intact ambulates w/o limp or alteration in gait extremities strong w/o atrophy no gross motor deficits sensation symmetrical & grossly intact no involuntary movements or tremor tardive dyskinesia tics

Speech/Vocalization: normal for age clear & coherent slurred mumbling to self monotonous stuttering hypoverbal hyperverbal loud soft slow rapid pressured groaning sighing crying perseveration flight of ideas repetitive questions self-depreciating statements repetitive statements of impending doom repetitive non-health related/financial concerns personal safety concerns suicidal ideation/threats insisting on particular medication, test, referral, or accommodation raising voice defensive/argumentative cursing/swearing previous providers/staff criticisms verbal threats sexual remarks racist remarks

Behavior/Psychomotor Activity: calm, pleasant, respectful cooperative with history & exam guarded anxious irritable frustrated labile agitated hostile forceful pacing fidgeting picking skin twirling hair cracking knuckles grimacing, furrowing eyebrows tightening jaw breathing hard intense staring threatening gestures fist-clenching withdrawn flat affect bradykinetic indifferent appears to be responding to internal psychotic process

AFFECTED AREA: FROM DROM minimal erythema moderate erythema significant erythema minimal discharge moderate discharge significant purulent discharge significant warmth/tenderness no ssx dehiscence sutures/staples intact dehiscence

PLAN OF CARE: patient/family verbalized understanding of dx & POC, agreed with dx & POC did not agree with dx & POC – encouraged to seek second opinion

PROCEDURE: skin cleaned with wound cleanser skin cleaned with Hibiclens skin cleaned with Betadine skin cleaned w NS drain/packing removed closure material removed small amount of purulent discharge observed some discharge observed packing inserted dry sterile dsg applied non-adherent dsg applied bulky gauze dressing applied splint/brace applied minimal/no bleeding motor, sensory. vascular assessment intact tolerated procedure well

MATERIAL REMOVED:
Type:

Quantity:

MATERIAL INSERTED:
Type:

Quantity:

ORDERS - MA: injection Rocephin 1 gm IM now Dexa 8 mg IM now none

ORDERS - RX: OTC electronic paper given to MA to be transmitted to pharmacy none

ORDERS - LABS: CBC CMP TSH A1C Lipids PSA UA none

ORDERS - IMAGING: X-ray US MRI none

WORK/SCHOOL STATUS: excuse from school/work no PE/gym fit for duty w/o restrictions fit for duty with restrictions return to school/work none requested

REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, reporting medication side effects immediately, appropriate follow up specific to condition, indications for immediate direct (re)evaluation and/or contacting emergency services, medications previous visits laboratory/diagnostic studies keeping wound dry changing dressing at least daily and when soiled cleaning area with soap and water and covering with non-adherent dsg expect call from clinic for any abnormal diagnostic studies contact clinic for diagnostic results if not received call specialty reports hospital discharge medication compliance controlling chronic conditions

DISCHARGE CONDITION/SAFETY: improved stable unchanged appears well non-toxic physical exam unremarkable for any emergent condition no safety concerns at this time safety concerns d/t depressed agitated mood safety concerns d/t impulsiveness safety concerns d/t hostile temper safety concerns d/t past attempts safety concerns d/t current suicidal verbalization

DISPOSITION: home referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left exam room before visit conclusion asked to leave clinic quarantine 10-14 days

FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, here in-person televisit w PCP 24 hours 2-3 days 1 week f/u acute episode f/u labs f/u imaging f/u med change/new

BARRIERS TO CARE: incomplete history poor cooperation with exam language barrier affect socio-cultural factors vague shifting complaints history not supported by objective findings supporting documentation unavailable poor compliance with POC intolerance of/therapeutic failure on multiple meds negative attitude to diagnostic impression & proposed tx lack of interest in nonpharmacologic therapies preoccupation with illness catastrophization overgeneralization unrealistic beliefs negativism pessimism blaming others hostile/disruptive behavior none noted at this time

Procedure – Dsg change, Suture/staple removal

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