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  • Topic: Glaucoma, Basal cell carcinoma, Cataract
  • Pages : 10 (2379 words )
  • Download(s) : 768
  • Published : October 3, 2012
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Chart Note 4.2

Comes to the office today for Botox injections. He has a very significant and rather severe left-sided hemifacial spasm.

Informed consent was obtained from the patient. Under sterile conditions, he received a total of 78.75 units of Botox. Location and dosages of injections are documented on his injection form. He tolerated these well. No complications were noted. He will follow up in 3 months when further injections are needed. He is to call the office in 2 weeks and let us know how well he is doing. If at that time he needs a touchup of the injections, we certainly will proceed from there.

I did tell the patient that the first time someone is injected, it is somewhat difficult to know the exact dose. We need to try a dose-response curve with him with the injections. Overall we should be able to get somewhere in the range of 90% relief of the hemifacial spasm.

Emergency Department Note 4.3

This is a 21-year-old female patient who presents to the emergency department complaining of having been bitten while she was at work 2 days ago. Patient reports that a client bit her on the right upper arm while they were trying to sit him up in a chair for dinner. The patient reports that the skin was broken.

She denies any fever, nausea, vomiting, neck pain, back pain, or abdominal pain.

Vital signs: Temperature 36.5, pulse 90, respirations 18, blood pressure 113/64. She is alert and oriented. No acute distress.

Patient reports that she has completed the hepatitis B vaccination series.

On physical exam, patient’s right upper arm has small superficial abrasions. There is minimal bruising. There are no signs of infection at this time, 48 hours later.

Patient was given a tetanus shot, and after discussion, for patient’s confidentiality reasons and due to low risk of this event, she will follow up with the health center where she gets her medical care for an HIV test and hepatitis titer tomorrow. She will return for any problems or complications. She was given aftercare instruction sheets for wound care.

DIAGNOSIS

Right upper arm human bite.

Chart Note 4.4

The patient had basal cell carcinoma of the lip. The patient has basal cell nevus syndrome and forms numerous skin cancers. Because of the location and nature of her syndrome, maximum preservation of normal tissue as well as complete eradication are indicated and best accomplished with the Mohs technique.

Chart Note 4.6

SUBJECTIVE

The patient is here for open wound of the right lower extremity. Patient thinks this area is healed. There is no redness or discomfort. There has been no drainage. There has been minimal swelling.

OBJECTIVE

Elderly female. No acute distress. Blood pressure 130/70. Skin warm and dry. Right lower extremity with only trace edema. No cyanosis. Open wound of the right shin, anterior distal leg, appears epithelialized. There is no tenderness, no exudate, no surrounding erythema.

ASSESSMENT

This is an elderly female who had suffered an injury to the right lower extremity which has now epithelialized. The patient is hereby discharged from our care. She is encouraged to keep the area off-loaded, protect the local area, elevate whenever possible to help control the limited edema she does have, and to return to this clinic if there are any future problems.

FINAL DIAGNOSES

1. Open wound of the right lower extremity, complicated, healed. Edema. 2. Discoid lupus.

CHART NOTE 4.7

Presents for routine care of elongated nails. Pertinent medical history: Parkinson’s disease.

Observed elongated nails with hammer digits, the 2nd and 3rd toes, right foot. Callus on the distal aspect of 2nd and 3rd, right. Elongated, thickened nails x10. No other problems noted. Neurovascular status intact. Temperature normal.

ASSESSMENT

Onychomycosis.

PLAN

Aseptic debridement of clavi. Debridement of nails x 10. Patient to return in 10 weeks.

Chart Note 5.1

This 67-year-old Native...
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