100%(4)4 out of 4 people found this document helpful
This preview shows page 5 - 7 out of 8 pages.
GenitourinaryNegative 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 leftlabia. Compression of cyst cheese like foul smelling substance expressed 2ml total. Presence of other smaller sebaceous cyst throughout the vulva smaller than .5 cm. MusculoskeletalN/ANeurological N/APsychiatricN/A Lab Tests (list the results if you have them)N/ASpecial Tests (done or ordered during the OV)Diagnosis – include the appropriate ICD – 10 Code for each diagnosis usedPrimary Diagnosis5
oSebaceous Cysts N90.7 – Positive for cheese like foul smelling substance expressed fromvulva.Differential Diagnoses o1- Contact Dermatitis – L24.9 – Positive for erythema, pain. Negative for symptom onset in 12 hours of exposure, acute erythema, edema, vesicles, ulcerations, scales, excoriation. o2 – Bartholin’s Duct Abscess N75 – Presence of erythema and swelling. Bartholin locatedat 5 & 7 o’clock and Bartholin glands are not infected. Temperature normal range. o3- Hidradenitis Suppurativa L72 –. Positive for erythema and swelling on the vulva. Negative for painful lymph nodes, drainage or abscess/ Plan/Therapeutics (explain fully)oPlan: 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 tooffice. Avoid contact with irritants, chronic moisture, feminine products. Avoid