Genitourinary Negative for Bladder distention or CVA tenderness External

Genitourinary negative for bladder distention or cva

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Genitourinary Negative for Bladder distention or CVA tenderness. External genitalia: pubic hair distributed evenly; skin color consistent w/ general pigmentation. Positive for erythema and swelling of vulva. Right vulva 3 fluid masses noted. Cyst 1- 1o’clock .5 cm, cyst 2 - 3 o’clock 1.0cm, cyst 3- 6o’clock 1.2cm. 3 areas of on the left labia. Compression of cyst cheese like foul smelling substance expressed 2ml total. Presence of other smaller sebaceous cyst throughout the vulva smaller than .5 cm. Musculoskeletal N/A Neurological N/A Psychiatric N/A Lab Tests (list the results if you have them) N/A Special Tests (done or ordered during the OV) Diagnosis – include the appropriate ICD – 10 Code for each diagnosis used Primary Diagnosis 5
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o Sebaceous Cysts N90.7 – Positive for cheese like foul smelling substance expressed from vulva. Differential Diagnoses o 1- Contact Dermatitis L24.9 – Positive for erythema, pain. Negative for symptom onset in 12 hours of exposure, acute erythema, edema, vesicles, ulcerations, scales, excoriation. o 2 – Bartholin’s Duct Abscess N75 – Presence of erythema and swelling. Bartholin located at 5 & 7 o’clock and Bartholin glands are not infected. Temperature normal range. o 3- Hidradenitis Suppurativa L72 –. Positive for erythema and swelling on the vulva. Negative for painful lymph nodes, drainage or abscess/ Plan/Therapeutics (explain fully) o Plan: applied topical lidocaine 1% to affected area for 30 minutes. Then expressed substance. Reevaluate in 4 weeks after incision and drainage of cysts. Further testing N/A Medication: Education: No baths for 48 hours. Only showers. Keep area dry avoid excessive wetness. Avoid contact sports and strenuous activities. Scar will take about 8 weeks to heal. Return if signs of infection appear. If cyst re-appear do not squeeze and pick with them. cyst should resolve on their own. If persist return to office. Avoid contact with irritants, chronic moisture, feminine products. Avoid
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