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**Chief Complaint:**
Rash on right calf with swelling and tenderness.

**History of Present Illness:**
The patient joined a gym 1 month ago and noticed the onset of the rash 1 week prior to this visit. The rash began with redness and progressed to small blisters. He had a fever since yesterday with chills, malaise, and dizziness.

**Past Medical History:**
The patient does not smoke. No prior operations.

**Review of Systems:**
There is itching between the 1st and 2nd digits of the right foot for approximately 1 month. PERRLA. No difficulty breathing or swallowing. Denies chest pain, nausea, or vomiting. No known allergies.

**Physical Examination:**
- **General:** This is a well-nourished, well-developed 22-year-old white male who is pleasant and cooperative.
- **Vital Signs:** Pulse: 100, regular. Temperature: 102 °F.
- **HEENT:** Normocephalic. Eyes: EOMs intact. Ears: Tympanic membrane is normal to inspection.
- **Neck:** Supple, no adenopathy.
- **Chest:** Heart and lungs normal to percussion and auscultation.
- **Abdomen:** There is a right inguinal adenopathy. Abdomen is soft without evidence of organomegaly.
- **Rectal:** The prostate is normal in size. No blood is seen on the examining finger. Stool guaiac negative.
- **Extremities:** There is a large, well-demarcated, shiny, red, edematous, tender rash covering most of the lateral aspect of the right leg with peripheral tenderness. Vesicles are present. In addition, there is an intertriginous rash between the first and second digits of the right foot.
- **Neurologic:** Except for the tenderness in the right leg, no deficits are demonstrated. DTRs are normoreflexive.

**Impression:**
1. Febrile vesicular rash, right leg, most likely erysipelas.
2. Intertriginous fungal infection of the foot.

**Plan:**
- Prescribe Pen. Vee K 250 mg p.o. q.i.d. on an outpatient basis for 14 days.
- Cold packs for pain.
- Aspirin 600 mg p.o. q.3 h. p.r.n. for pain.

**E/M: _____**

Answer :

The patient is most likely suffering from erysipelas in the right leg and an intertriginous fungal infection of the foot. Treatment includes Pen. Vee K, cold packs, and aspirin. Immediate medical attention is recommended due to the fever and symptoms.

CHIEF COMPLAINT: Rash on right calf with swelling and tenderness.

HISTORY OF PRESENT ILLNESS: The patient joined a gym 1 month ago and noticed the onset of the rash 1 week prior to this visit. The rash began with redness and progressed to small blisters. He had a fever since yesterday with chills, malaise, and a dizzy sensation.

PAST MEDICAL HISTORY: The patient does not smoke. No prior operations.

REVIEW OF SYSTEMS: There is itching between the 1st and 2nd digits of the right foot for approximately 1 month. PERRLA. No difficulty breathing or swallowing. Denies chest pain, nausea, or vomiting. NO KNOWN ALLERGIES.

PHYSICAL EXAMINATION:

  • GENERAL: This is a well-nourished, well-developed 22-year-old white male who is pleasant and cooperative.
  • VITAL SIGNS: Pulse: 100, regular. Temperature: 102 °F.
  • HEENT: Normocephalic. Eyes: EOMs intact. Ears: Tympanic membrane is normal to inspection.
  • NECK: Supple, no adenopathy.
  • CHEST: Heart and lungs normal to percussion and auscultation.
  • ABDOMEN: There is a right inguinal adenopathy. Abdomen is soft without evidence of organomegaly.
  • RECTAL: The prostate is normal in size. No blood is seen on the examining finger. Stool guaiac negative.
  • EXTREMITIES: There is a large, well-demarcated, shiny, red, edematous, tender rash covering most of the lateral aspect of the right leg with peripheral tenderness. Vesicles are present. In addition, there is an intertriginous rash between the first and second digits of the right foot.
  • NEUROLOGIC: Except for the tenderness in the right leg, no deficits are demonstrated. DTRs are normoreflexive.

IMPRESSION: Febrile vesicular rash, right leg, most likely erysipelas.

Intertriginous fungal infection of the foot.

PLAN: Prescribe Pen. Vee K 250 mg p.o. q.i.d. on an outpatient basis for 14 days. Cold packs for pain. Aspirin 600 mg p.o. q.3 h. p.r.n. for pain.

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Rewritten by : Barada

The appropriate Evaluation and Management (E/M) code for this outpatient visit is 99203.

  • This encounter is an outpatient new patient visit.
  • The history provided is detailed, covering the chief complaint, history of present illness, past medical history, and a review of systems.
  • The physical examination is detailed, covering multiple systems.
  • The medical decision-making is of low complexity, involving the diagnosis and treatment of febrile vesicular rash and intertriginous fungal infection.
  • According to CPT guidelines, E/M code 99203 corresponds to an outpatient new patient visit with a detailed history, a detailed examination, and medical decision-making of low complexity.