| |
|
|
|
| |
42 year old male referred to allergist to be evaluated for allergic reaction to spider bite
Reason for consult : Evaluation and management of insect bite
Requesting physician : John Doe, MD
HPI :The patient states he was cleaning out a shed in his back yard yesterday when he was bitten by a brown spider on the left thumb. The bite was initially described as “really, really painful”, but has since improved. The patient noted worsening redness and swelling of the thumb last evening. He is referred for evaluation to rule out possible allergic reaction to the venom.
ROS
Cardiovascular - Negative for palpitations, racing heartbeat, chest pain
Pulmonary - Negative for wheezing, cough or dyspnea
Physical Exam
General: No acute distress, conversant, well nourished male
Vitals: 120/80, 98.6, 72
Lungs: CTA
CV: RRR, no MRGs
Extremities: No peripheral edema or digital cyanosis
Skin: left thumb has a 1 mm punctate lesion with an erythematous base and minimal induration;
there is mild soft tissue swelling
Assessment
- Simple spider bite
- Mild localized inflammation, with no evidence of systemic allergic reaction to venom
Plan
- Superficial dressing placed
- Routine wound care instructions provided
- Return visit if worsening swelling or redness
- Will send a copy of this note to Dr. Doe
For a detailed breakdown of this note with tips and advice see 99242 E/M Insight
|
|
|
|
|
|
|
|
|
 |
 |
 |
