CHIEF COMPLAINT: Rash.

HISTORY OF PRESENT ILLNESS: This is a very pleasant (XX)-year-old who was brought to the emergency department today by mom. Apparently, the child developed a rash over the past few days.

Mom states that the child was with her dad. She is not sure if there were different laundry detergent use or soaps; although, he tends to use the same things they do, but she is concerned because the child has developed a rash on her buttocks as well as in the front trunk area.

She thinks it may be spreading to her neck as well. She states the child scratches here and there but not excessively. There has been no fever. No vomiting. No diarrhea. Child has been acting normal. Otherwise, no complaints of pain.

PAST MEDICAL HISTORY: Negative.

MEDICATIONS: None.

IMMUNIZATIONS: Up-to-date.

SOCIAL HISTORY: Here with mom.

REVIEW OF SYSTEMS: As noted in the HPI. The remainder 10 is negative unless otherwise stated.

PHYSICAL EXAMINATION:
GENERAL: Examination reveals a (XX)-year-old who is adorable. She is awake. She is alert. She is age appropriate. She appears in absolutely no distress. She is nontoxic in appearance.
VITAL SIGNS: She is afebrile.
HEENT: Head is normocephalic and atraumatic. Pupils are equal and reactive. Extraocular movements are intact. Nares patent. Throat is clear. TMs are intact.
NECK: Soft and supple.
LUNGS: Clear without wheezes.
HEART: Regular.
ABDOMEN: Soft.
SKIN: She has evidence of a maculopapular pinpoint rash that is noted on the buttocks, somewhat in the groin area. Mom states she sees it on the neck; I really do not see it there. She states she could feel it starting to form on her back. It seems to be in the distribution of her underwear. Mom states that she has not had pull-ups on in a few days as sometimes those can tend to give her a rash.

MEDICAL DECISION MAKING: At this point, I do not know the etiology of this rash. I told mom it does not appear consistent with scabies, bed bugs, cellulitis, MRSA, nothing to suggest chickenpox or roseola. She was using some Aquaphor, which I do not think could hurt. They can use some Benadryl if she is itching; otherwise, they would see the pediatrician. Nothing to suggest anything toxic. The patient is seen in collaboration with Dr. John Doe.

CLINICAL IMPRESSION: Rash.

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CHIEF COMPLAINT: Spider bite, left knee.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who comes to the emergency department complaining of a spider bite to his left knee. The spider bite has been there for several weeks.

He has had one abscess to his chest that he has cut open several times himself and has had drain copious amounts at a time but this is actually healed over. There is one area on his leg that is healing, but the area on his right knee is red, draining and very painful.

He denies any fevers. He says it hurts when he stands and walks. This all started with the abscess on his chest. He says that now he has had these areas on his legs. He is not sure how they are happening.

Pain is 10/10. Nursing notes reviewed.

REVIEW OF SYSTEMS: He denies weakness, numbness or tingling. Review of systems otherwise negative.

PAST MEDICAL HISTORY: None.

ALLERGIES: None.

CURRENT MEDICATIONS: None.

IMMUNIZATIONS: Up to date.

SOCIAL HISTORY: He does smoke one pack of cigarettes a day.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8, pulse 68, respirations 18, blood pressure 106/82, pulse 97%.
GENERAL: Well-appearing, nontoxic (XX)-year-old male. He is alert. He is oriented x3. He is calm and cooperative during exam.
EXTREMITIES: Over the right knee, this is over the inferior portion over the proximal tibia, there is an abscess. This is open and draining. There is an area of surrounding cellulitis, very tender to palpation. Full range of motion of the knee with very minimal pain over the medial aspect of the knee. There is a healing abscess in the left lower extremity. There is a healed abscess over the left chest right along the left nipple.

DIAGNOSTICS: None.

PROCEDURE: The area was prepped with Betadine, infiltrated with total of 9 mL bupivacaine without epinephrine with good results. The area was opened further with an 11 blade. Hemostats were inserted in the wound to break up loculated fluid and debride this area. Unfortunately, this was not able to be packed. The area was bandaged.

MEDICAL DECISION MAKING: The patient has cut this open several times. This is open and draining. This was attempted to be opened further by myself. The whole top of this was basically opened up. Therefore, there is no packing that was able to be placed.

IMPRESSION:
1. Left knee draining abscess.
2. Resolving left knee and left chest abscess.

DISCHARGE INSTRUCTIONS:
1. Follow up with medicine on-call in 2 days for wound check.
2. Return for pain, redness and swelling.
3. Wound care instructions.
4. Bactrim DS 2 p.o. b.i.d. x10 days.
5. Vicodin, total of 15 tablets.

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HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a history of prostate cancer with metastases to the bone and colon, who comes in complaining of left lower rib pain for the last 3 weeks.

He denies any recent trauma. It is worse with activity. He denies any pain when he is at rest. He states that there is no pain on deep inspiration. It is reproducible on palpation. He denies any radiation.

He says that it is an 8/10 on a pain scale. No relief with over-the-counter NSAIDs. It is interfering with his work.

PAST MEDICAL HISTORY:
1. Prostate cancer.
2. Metastases to the bone.
3. Metastases to the colon.

CURRENT MEDICATIONS: Casodex.

ALLERGIES: None.

SOCIAL HISTORY: The patient denies any smoking, denies alcohol use and denies drug use.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: No chest pain, shortness of breath, nausea, vomiting or diarrhea. No fever or chills. Left-sided rib pain is positive. All other review of systems negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: On presentation, temperature 98.4, blood pressure 144/58, pulse 78, respirations 18, pulse oximetry 99% on room air.
GENERAL: The patient was not appearing in any acute distress, well-nourished, awake, alert and oriented.
HEENT: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular movements intact. Mucous membranes are moist.
NECK: Range of motion is 100% in all 4 directions.
CHEST: Clear to auscultation bilaterally. On palpation, he did have some mild tenderness in the left lower ribs, around rib 9, 10, and 11 on palpation.
HEART: Regular rate and rhythm. S1, S2, no murmurs appreciated.
ABDOMEN: Soft, nontender, nondistended. No organomegaly appreciated. Positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema. Pulses are palpable 2+ bilaterally.

LABORATORY DATA: WBC 5.0, hemoglobin 12.8, hematocrit 39.6, platelet count 169. Sodium 138, potassium 3.9, chloride 104, BUN 16, creatinine 1.1, glucose 168. Cardiac enzymes: CK 674, CK MB 2.9. Troponin I is less than 0.1.

X-RAY: X-ray was read as negative.

EKG: No changes from previous. No signs of injury or infarct.

EMERGENCY DEPARTMENT COURSE: The patient was evaluated, received morphine 4 mg IV for his pain control.

MEDICAL DECISION MAKING: This is a (XX)-year-old male who comes in complaining of left-sided rib pain. It was originally thought that maybe he had a rib fracture. X-rays were obtained which were read as negative, possible consideration for atypical chest pain. The EKG did not show any changes from previous, and the first set of cardiac enzymes was negative. It is currently felt that he has just exacerbated musculoskeletal pain. Bony metastases were not present on x-ray. So, he will be discharged home in stable condition with prescription for Vicodin 5/500, #30 pills.

IMPRESSION/DIAGNOSIS: Musculoskeletal pain.

PLAN:
1. The patient will be discharged in stable condition.
2. Prescription for Vicodin.
3. He is to follow up with the Hematology/Oncology physician in 1 week.
4. He is to return for any worsening of symptoms.

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HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who has had syncope 7 times recently. He got up to go to the bathroom and then found that his legs were shaking, and his wife thought he was having a seizure.

EMS was summoned. His blood sugar was too low to read, given amp of D50, and brought him here. Family states his blood sugar was low this morning at 40. They gave him some juice.

PAST MEDICAL HISTORY: Hypertension, hypercholesterolemia, colon cancer with colostomy, bowel obstructions and diabetes mellitus.

SOCIAL HISTORY: Nonsmoker and nondrinker.

MEDICINES: Tricor, Lortab, Celexa, Coumadin, Flomax, Amaryl, glyburide, Nexium, Flomax, Avapro, Compazine and metoprolol.

ALLERGIES: None.

REVIEW OF SYSTEMS: As in HPI. He has no headache. No chest pain. No shortness of breath. No abdominal pain. No fever. No vomiting. No dysuria. All the systems were reviewed and negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 98/50, heart rate 88, respirations 18, temperature 36.2, and O2 saturation is 94% on room air.
GENERAL: This is an awake and alert male in no acute distress.
HEENT: Pupils are equal, round and reactive to light. No scleral icterus or pallor. Nares without drainage. Oropharynx is dry. No erythema.
HEART: Regular rhythm. No murmurs.
LUNGS: Clear to auscultation bilaterally with no rales or wheezes.
ABDOMEN: Soft, nontender and nondistended. Normoactive bowel sounds. He has a colostomy bag with stool.
EXTREMITIES: Warm.
SKIN: Without rash. Pulses are 2+ x4. No calf tenderness or edema.
NEUROLOGIC: Cranial nerves II through XII intact bilaterally. Muscle strength 5/5. Sensory intact to light touch x4. DTRs are 1+ and symmetric.

EMERGENCY DEPARTMENT COURSE: The patient had an IV established by EMS. He was given a 500 mL normal saline bolus here bringing his blood pressure up into the 120s. He had an electrocardiogram showing normal sinus rhythm with T-wave inversions in V2 and V3, which appeared to be new from previous EKG. No ST segment changes.

LABORATORY DATA: Comprehensive metabolic panel; sodium 134, BUN 36, creatinine 1.6 and glucose 64. Initial i-STAT showed a pH of 7.25, bicarbonate 18, potassium 5.2, and BUN 36. CBC: White count 6.6, hemoglobin 12.2, platelets 246, differential 87%, and neutrophils without bands. PT 15.8 with an INR of 1.2, CK and total MB normal with a troponin less than 0.02.

We repeated a blood sugar on him shortly after arrival and it was again low at 42. He was given an amp of D50 and 1 L of D5 normal saline bolus under my supervision. Given his recurrent hypoglycemia on oral agents and worsening renal function versus dehydration, we felt he should be admitted as the risks for recurrence of hypoglycemia is high within the next 24 hours.

We spoke with Dr. John Doe, on-call for the hospitalist service, and his primary care physician. He is aware of the patient’s EKG changes from previously as well. The patient is not having any chest pain, and his cardiac enzymes were negative.

DIAGNOSES:
1. Recurrent hypoglycemia.
2. Falls.
3. Dehydration and renal insufficiency.
4. EKG changes.

CONDITION ON ADMISSION: Stable.

Care was transferred to Dr. John Doe. At the time of admission, we did repeat blood glucose on this patient and it was 128 after an hour.

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HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has been recently admitted for pneumonia. The patient was actually just discharged yesterday. She has been at home and not feeling well.

She started to have some vomiting and has noticed that her blood pressure has been high. She continues to feel nauseated and not well and now here for evaluation.

The patient denies any diarrhea; in fact, she has been constipated. She has not had a bowel movement for 7 or 8 days. She denies any abdominal pain however.

PAST MEDICAL HISTORY: Significant for thyroid surgery. The patient has arthritis in her back and on home oxygen since her discharge yesterday at 6 liters.

CURRENT MEDICATIONS: Amlodipine, prednisone, thyroid medication, albuterol.

ALLERGIES: None.

SOCIAL HISTORY: The patient lives with a companion who accompanies her here today. She has smoked in the past but has quit. She occasionally drinks alcohol.

REVIEW OF SYSTEMS: Unremarkable for fever. The patient feels no shortness of breath, no cough. She denies abdominal pain but does have nausea and vomiting as well as constipation. She has had swelling in bilateral legs. This has been going on for years. She said normally the swelling is worse in the right than on the left. She has tried different medications for this, which have not seemed to work. The swelling is not any worse than usual at this time. The patient has no dysuria, and she denies any other system complaints at this time.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 36.3, heart rate 102, respiratory rate 22, blood pressure in the right arm 166/92, in the left arm 154/78, 02 sat 93% on 6 liters nasal cannula.
GENERAL: The patient is awake, alert, oriented, in no obvious distress, speaking long full sentences.
SKIN: Warm and dry with no rash.
HEENT: Pupils reveal some postoperative changes, mostly on the left. The right pupil is reactive. Pharynx with moist mucous membranes.
NECK: Supple, nontender with no JVD.
LUNGS: Respirations are clear and equal bilaterally with no wheezes, rales or rhonchi.
HEART: There is a regular rate and rhythm, although slightly tachycardiac initially.
ABDOMEN: The abdomen is soft and nontender. There is minimal distention, but there is no pain with deep palpation, no focal tenderness, no mass.
EXTREMITIES: The patient is moving all extremities with minimal edema of the bilateral lower extremities and no deformities or tenderness.
NEUROLOGIC: Intact sensation distally.

IMPRESSION: The patient may have continued pneumonia causing her to feel unwell. My main concern at this time is her nausea and vomiting. She has not had a bowel movement for the last 7-8 days. I am concerned that she may have severe constipation or obstipation, and she may have an ileus or bowel obstruction causing her to have these problems.

The patient did have some vomiting upon admission last time and it was felt to be probable viral illness, but she has since started to vomit again and my concern is for bowel obstruction or ileus. As far as the high blood pressure is concerned, the patient’s main concern today was the high blood pressure, but her blood pressures in the emergency room have not been terribly high.

DIAGNOSTIC/LAB STUDIES: Chest x-ray revealed an ill-defined opacity in the left lower lobe as well as some small bilateral pleural effusion. Abdominal x-ray reveals findings suggestive of an early small bowel obstruction or ileus.

Lipase is high at 756. Comprehensive metabolic panel reveals sodium of 135, BUN is high at 35, but creatinine 1.1, ALT high at 238, and AST of 114. Magnesium is normal. Troponin less than 0.02, CBC with a white count of 13.2, normal hemoglobin and hematocrit and platelets.

EKG interpretation by ER physician reveals a sinus rhythm of a ventricular rate of 98. There are non specific ST-T wave changes, but no acute injury pattern is noted.

EMERGENCY ROOM COURSE: IV was started. The patient was placed on a monitor and oxygen to keep her oxygen saturations greater than 90%. On about 5 liters, the patient is able to remain with oxygen saturations in the low 90s.

She remains relatively comfortable in the ER while she is here, except she does have some vomiting, so she was given Zofran 4 mg IV to help with this, and her vomiting was controlled after she was given the Zofran.

The patient has signs of a possible early bowel obstruction and is vomiting. We felt the patient should stay in the hospital for further evaluation until this resolves. We discussed the case with Dr. John Doe, who is covering for the patient’s primary care physician. He accepted the patient to the hospital for further care. The patient was comfortable with the plan, and was stable on transfer to the medical floor under the care of Dr. John Doe.

DIAGNOSIS: Ileus and vomiting, elevated liver enzymes and pancreatitis.

PLAN: Admission to the medical floor under the care of Dr. John Doe.

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HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who states that he has had rectal pain that started 7 days ago after he was very constipated and a large bowel movement came out. He says that he felt like he cut himself as this occurred.

He was seen and evaluated in the clinic by Dr. John Doe, diagnosed with rectal fissures. The patient was prescribed some medicine for his rectum, but he did not think it helped.

The patient says that he did not know how much of cream he is supposed to put in, and he has also been taking some laxatives, so he says his constipation seems to have resolved. He is also taking prune juice.

PAST MEDICAL HISTORY: History of depression, hypertension, diabetes, and anxiety.

SOCIAL HISTORY: He is retired. He is single.

FAMILY HISTORY: Noncontributory.

MEDICATIONS: Metformin and insulin.

ALLERGIES: Sulfa and penicillin.

REVIEW OF SYSTEMS:
GASTROINTESTINAL: The patient reports that he is not having any pain towards his belly. He has not been vomiting.
CONSTITUTIONAL: The patient denies fevers or chest pain. There were no systemic complaints.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 36.2, pulse 90, respiratory rate 16, blood pressure 122/94, and pulse ox 96% on room air, which is normal.
GENERAL: This is a (XX)-year-old male who is sitting upright.
HEENT: Normocephalic. Pupils are equal and reactive. The patient’s oropharynx is clear.
LUNGS: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, nondistended, and nontender.
RECTAL: The patient’s rectal exam was done with the nurse present. In fact at that time, he also had anoscopy that was done and it showed that there is an area of small rectal fissures that are present across the superior left of the rectum without any current bleeding. The patient has no palpable hemorrhoids that are present on rectal exam digitally.

DIFFERENTIAL DIAGNOSES: Rectal fissures, constipation, and local trauma.

EMERGENCY DEPARTMENT COURSE: The patient denies any type of local trauma except for trying to pass this larger stool and the only thing that I see on exam after anoscopy is rectal fissures. The patient has been given the information to follow up with the on-call surgeon, if his pain is not improving.

We have written for Anusol-HC suppositories, a total of 20 dispensed, see if he will do a little better with the suppositories and the cream. Also, he was given 15 Lortab as prescription. We have recommended Metamucil rather than laxatives at home.

DIAGNOSES:
1. Rectal fissures.
2. Diabetes.

DISPOSITION: Discharged.

DISCHARGE CONDITION: Good.

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HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old otherwise healthy African American female who presented to the emergency department with the above complaint. The patient states at approximately 2:00 this afternoon, she was bit by a chihuahua.

The patient states she did, at that time, ask the owner if the dog’s vaccinations are up-to-date and they are current per the owner. The patient states that, when she returned home, she thoroughly cleaned out the area and put some Neosporin and a bandage on there.

The patient states she then still had some pain and thought she needed followup. The patient describes this as a throbbing, achy sensation, rating it a 8/10. The patient has not yet taken over-the-counter Tylenol or ibuprofen for this pain. The patient is unsure when her last tetanus vaccination was; however, the patient states she does know it was greater than 5 or 6 years ago.

The patient currently has no primary physician to see regarding this. The patient denies any numbness or tingling of that extremity or decreased range of motion. The patient also denies any other puncture wounds secondary to this bite.

PAST MEDICAL HISTORY: The patient denies.

CURRENT MEDICATIONS: None.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient smokes 1 pack of cigarettes a day. He denies use of alcohol and illicit or IV drugs.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: As stated above, otherwise negative per the patient.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 138/82, pulse 66, respirations 22, temperature 98.8 and O2 saturation 99% on room air.
GENERAL: This is a well-developed, well-nourished (XX)-year-old female who is alert and oriented x3 and appears to be in no acute distress. The patient is cooperative and communicates well and was ambulatory here in the emergency department.
HEENT: Normocephalic and atraumatic. Eyes: Equal, round and reactive to light and accommodation. Extraocular movements are intact bilaterally. Conjunctivae are pink without discharge. Sclerae are nonicteric. TMs appear clear. Buccal mucosa is pink and moist. Pharynx is without erythema or exudate.
NECK: Supple without lymphadenopathy. Trachea is midline.
LUNGS: Clear to auscultation bilaterally. No wheezing, rales or rhonchi noted.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops noted.
ABDOMEN: Soft, nondistended, nontender to palpation in all 4 quadrants. There is no rebound or guarding noted. No masses noted either. Bowel sounds present in all 4 quadrants.
EXTREMITIES: Distal pulses 2+ bilaterally. The patient has full range of motion of all extremities. Sensation is intact to light touch. Muscle strength is 5/5 of all extremities. Upon further examination of the patient’s right lower extremity, she has 2+ dorsal pedis and posterior tibialis pulses. The patient has intact sensation to light touch. The patient does have a small puncture wound noted to the dorsal aspect of her right foot with no active bleeding. The patient has no puncture wounds noted. Upon examination, we did not notice any foreign body. The patient had full dorsi and plantarflexion of that foot. The patient had no edema or drainage from this area. The patient had brisk capillary refill.
NEUROLOGIC: Cranial nerves II-XII are intact. DTRs are 2+ bilaterally of both upper and lower extremities. Muscle strength 5/5 of all extremities. No focal deficits noted.
SKIN: Warm and dry to touch.

EMERGENCY DEPARTMENT COURSE: The patient was examined. At that time, her tetanus vaccination was updated here in the emergency department. The patient also had her wound thoroughly irrigated. Antibiotic ointment and dressing was applied. The patient tolerated this well.

IMPRESSION: This is a (XX)-year-old female who presents to the emergency department for a dog bite to her right foot. Upon examination, the patient was neurologically intact and no foreign body was noted. The patient did have a small puncture wound to the dorsal aspect of her right foot, which was thoroughly irrigated and a sterile dressing was applied. At this time, we do feel the patient is stable for discharge home, and she will be discharged with a prescription for Augmentin. The patient will also be given a clinic list for followup for persistent symptoms. The patient will also be given the next couple of days off of work.

DIAGNOSIS: Dog bite to the right foot.

PLAN:
1.  Augmentin 875 mg.
2.  Wound care instructions.
3.  Tylenol, ibuprofen as needed for pain.
4.  Elevate for swelling.
5.  Follow up with PCP.
6.  Return for any signs of infection such as increased redness, swelling, purulent drainage or other concerns.

DISPOSITION: The patient was discharged to home in stable condition.

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HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who comes to the emergency department with a complaint of a thumb laceration. This was on a rock. He was laying some rock out front of his house when a hatchet bounced off the rock and hit his thumb. He does not think his thumb is broken. He is able to move it without difficulty. He says the pain is really mild. He is able to feel everything. He has had plenty of stitches before. He states this is nothing new to him. He says he feels fine, just needs a few stitches. Nursing notes reviewed.

PAST MEDICAL HISTORY: None.

ALLERGIES: None.

CURRENT MEDICATIONS:
1. Naprosyn.
2. Lyrica.

IMMUNIZATIONS: Unknown.

SOCIAL HISTORY: The patient does not use tobacco products.

REVIEW OF SYSTEMS: The patient denies any weakness, numbness or tingling. Review of systems is otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 72, respirations 18, blood pressure 146/92, pulse 96%.
GENERAL: A well-appearing, nontoxic (XX)-year-old male. He is alert. He is oriented x3. He is calm and cooperative throughout the exam.
EXTREMITIES: Over the left thumb, over the radial aspect, there is a flap-like laceration. This does start to encompass the radial aspect of the nail. On further investigation, there is just a crack of the nail bed. It does not appear that there is a subungual hematoma. It does not appear we need to take off his nail. He is able to flex and extend the interphalangeal joint without difficulty. He has good sensation distally. He has good radial pulse at 2+.

DIAGNOSTICS: Three-view x-ray was taken of the left thumb and read as no fracture, no dislocation, foreign body.

PROCEDURE: The area was infiltrated with a digital block, 5 mL bupivacaine without epinephrine with good results. The area was scrubbed with Shur-Clens, 210 mL of normal saline under pressure. The wound was draped in the normal sterile fashion. The wound was explored, no foreign body seen or palpated. No tendon or joint involvement seen. This is a flap-like laceration. There is no bony tissue involvement. The area was closed using a total of 5 simple interrupted sutures with good wound approximation. PSO ointment was placed and a sterile bandage was applied.

EMERGENCY DEPARTMENT COURSE: Given a tetanus shot here.

MEDICAL DECISION MAKING: The patient is well appearing. There are no foreign bodies seen or palpated. He has good flexion, extension. There are no signs of decreased sensation. He is to follow up with his family physician in 7 to 10 days.

IMPRESSION: Left thumb laceration, 3 cm.

DISCHARGE INSTRUCTIONS:
1. Follow up with primary care physician in 7 to 10 days for suture removal.
2. Return for pain, redness or swelling.
3. Wound care.

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HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who apparently, for the last 4 days, has had a little bit of neck pain and difficulty swallowing. It started out mostly as left posterior neck pain and left submandibular area pain.

She saw her primary care physician initially and was placed on Amoxil 875 t.i.d. She thought this possibly could be early peritonsillar abscess or possibly even an abscessed tooth. The patient states that she has not gotten much better in the last couple of days. She continues to have some trouble swallowing and has quite a bit of pain.

Apparently, after consulting with her family physician again, a CT scan of the neck was obtained earlier today. After the results of this were available, the patient was told to come to the emergency department for further evaluation and treatment.

The CT scan of the neck revealed findings that are concordant with a left peritonsillar cellulitis without any signs of any abscess.

PAST MEDICAL HISTORY: No diabetes, cardiac or respiratory problem.

CURRENT MEDICATIONS:
1. Claritin-D.
2. Albuterol.
3. Zyrtec.
4. Amoxicillin.

MEDICATION ALLERGIES: None.

SOCIAL HISTORY: The patient does smoke. She does not drink.

REVIEW OF SYSTEMS: Negative at this time.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 130/82. Temperature 97.2. Pulse 94. Respirations 16. O2 saturation is 99%.
HEENT: Head is normocephalic. TMs are okay. Nose is clear. Throat: There is a little bit of erythema noted. It is more prominent on the left than the right. No exudate. There are no signs of abscess clinically. There is a small submandibular node on the left. She has no posterior adenopathy.
HEART: Regular rhythm and rate.
LUNGS: Clear.
ABDOMEN: Soft.

EMERGENCY DEPARTMENT COURSE: While in the emergency department, the patient did receive 10 of Decadron IM and a small amount of morphine, Phenergan and a liter of normal saline. She received 600 mg of IV clindamycin. This case was discussed with Dr. John Doe. He will be glad to follow her in the next couple of days.

We do not think the patient needs to be admitted. She is taking clears without much problem. There are no clinical signs of abscess. The CT scan reveals only cellulitis. Her Amoxil will be withheld. She will be started on clindamycin 300 q.i.d. for the next week. Lortab 5 as needed for pain. No work for the next few days.

DIAGNOSIS: Acute peritonsillar cellulitis, left greater than right.

PLAN: As above mentioned.

DISPOSITION: Discharged.

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DATE OF ADMISSION: MM/DD/YYYY

CHIEF COMPLAINT: Fever up to 105 at home.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female who presents with a chief complaint of fever up to 105 at home. Father states the child has had a cough, runny nose, which began over the past four days; however, these signs and symptoms are getting better. The father is worried because the patient’s fever is unchecked. She has been alternating between Motrin and Tylenol; however, she has not gotten any significant results. Specifically, the child denies any sore throat, earache, nausea, vomiting, or wheezing. The child has no bowel or bladder problems, and the last diaper was wet just prior to arrival.

PAST MEDICAL HISTORY: Unremarkable.

PAST SURGICAL HISTORY: Unremarkable.

FAMILY HISTORY: Unremarkable.

ALLERGIES: The patient has no known drug allergies.

MEDICATIONS: Tylenol and Motrin.

IMMUNIZATION: All immunizations are up-to-date.

REVIEW OF SYSTEMS: A 13-point review of systems was conducted and was negative for anything not specifically mentioned in the HPI.

PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished female, alert and oriented x4, nontoxic and in no acute distress.
VITAL SIGNS: Pulse 150, respirations 24, temperature 103.8 tympanic, pulse oximetry is 94% on room air, and weight is 11.40 kilos.
HEENT: Head is normocephalic without evidence of trauma. Eyes: Pupils are equal, round, and reactive to light and accommodation with all extraocular movements intact. There is no injection or icterus. Ears: Tympanic membranes are pearly gray. All landmarks present. No erythema or exudates. Nose: Midline without septal deviation. All mucous membranes are moist. Throat: Palate rises equally on phonation. There is no erythema or exudates.
NECK: Supple without palpable thyromegaly, nodules, or lymphadenopathy.
LUNGS: Clear to auscultation bilaterally without wheezes, rales, rhonchi, or stridor.
HEART: Regular rate and rhythm without murmurs, rubs, clicks, or gallops.
ABDOMEN: Nondistended. There is no tenderness or guarding.
EXTREMITIES: Extremities have a range of motion, which is full and equal bilaterally. Muscle strength 5/5.
NEUROLOGIC: Cranial nerves II through XII are grossly intact bilaterally. All deep tendon reflexes are +2 and equal symmetrically.
SKIN: Warm, pink, and dry. Turgor is within normal limits. There is no erythema or rash.

LABORATORY DATA: The patient received a nasopharyngeal swab for influenza, which was positive for influenza A. CBC was performed with white blood cell count of 12.9, RBC of 4.70, hemoglobin 11.8, hematocrit of 35.2, and platelet count of 294,000. Basic metabolic panel showed a sodium of 139, potassium 4.2, chloride 104, carbon dioxide 18, glucose 102, anion gap of 16, BUN of 12, creatinine 0.4. Urinalysis showed a specific gravity of 1.007, negative for leukocyte esterase, nitrites, ketones, or blood. A RSV nasal swab was performed and was negative for RSV.

EMERGENCY DEPARTMENT COURSE: The patient was given a saline lock, normal saline bolus of 3 mL per kilogram as well as Motrin 10 mg per kilogram.

CLINICAL IMPRESSION:
1. Influenza.
2. Fever.
3. Cough.
4. Congestion.

PLAN:
1. Benadryl 12.5 mg/5 mL 3-3/4 teaspoons p.o. q. 6 hours p.r.n. for cough.
2. Motrin liquid 100 mg/5 mL 3-3/4 teaspoons q. 6 hours.
3. Tamiflu 60 mg/5 mL, 2.5 mL p.o. q. 12 hours for 5 days.
4. Tylenol 160 mg/5 mL 3-3/4 teaspoons p.o. q. 4 to 6 hours p.r.n. fever.
5. The patient is to follow up with the primary care provider.
6. The patient’s father has been educated as to the signs and symptoms that would necessitate an early return to the emergency department.

The patient’s father verbalized understanding and states he will comply with our plan.

CONDITION: Stable.

DISPOSITION: Discharged.

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