Swollen Lymph Nodes

Patient presents with lymphadenopathy, characterized by swollen lymph nodes.  Location of affected nodes includes (specify location e.g., cervical, axillary, inguinal).  Node size is documented as (e.g., 1 cm x 2 cm), texture is (e.g., firm, rubbery, mobile, fixed), and tenderness is (e.g., present, absent).  Associated symptoms include (e.g., fever, chills, night sweats, fatigue, weight loss, upper respiratory infection symptoms, skin rash, sore throat).  Patient denies (list pertinent negatives e.g., recent travel, exposure to illness).  Differential diagnosis includes infection, lymphoma, autoimmune disease, and other malignancies.  Physical examination reveals (document relevant findings e.g., pharyngitis, skin lesions).  Initial diagnostic workup may include complete blood count (CBC) with differential, comprehensive metabolic panel (CMP), inflammatory markers (e.g., erythrocyte sedimentation rate (ESR), C-reactive protein (CRP)), and consideration for lymph node biopsy or imaging studies (e.g., ultrasound, CT scan) depending on clinical suspicion.  Patient education provided regarding possible causes of swollen glands, monitoring for changes, and follow-up care.  Plan is to (specify plan e.g., observe, treat underlying infection, refer to specialist).  Return to clinic scheduled for (specify timeframe) or sooner if symptoms worsen.  ICD-10 code R59.1 (localized lymphadenopathy) or other appropriate code based on specific clinical findings and etiology may be applied.  CPT codes for evaluation and management (E/M), laboratory tests, and procedures will be billed accordingly.