DATE OF ADMISSION: MM/DD/YYYY
PRIMARY CARE PHYSICIAN: John Doe, MD
CHIEF COMPLAINT: Possible spider bite to the right thigh.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old Hispanic male who has had some swelling in the right thigh for three days. The patient is wondering if it is a spider bite; although, he does not know for sure. The patient awoke with the swelling. It is getting worse. He also felt like there is some swelling on his chin; although, that is better than it was and presents for evaluation.
PAST MEDICAL HISTORY: None.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: None.
REVIEW OF SYSTEMS: The patient complains of swelling on the thigh. No fever, no trauma. The patient had some drainage. He presents for evaluation.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 138/96, temperature is 98.6, pulse 100, and respiratory rate 20.
GENERAL: The patient is awake, alert, is in no distress.
HEENT: There is a small papule on the chin consistent with a small pimple. There is nothing that we feel can be opened. On intraoral exam, he has got an area of swelling adjacent to the gingiva and buccal mucosa on the left side, frontal area, that is about 0.5 cm in size, consistent with an intraoral abscess. He refuses I&D of the intraoral abscess.
EXTREMITIES: Leg: The patient has got a 3 cm indurated area on the right thigh with some minimal surrounding erythema. There is some questionable fluctuance. There is no lymphangitis or lymphadenitis.
EMERGENCY DEPARTMENT COURSE: The patient was given morphine and Phenergan for pain. The area was prepped and anesthetized with 2% Xylocaine. The area was opened. Some purulent material was expressed.
PLAN:
1. He was to follow up with his family doctor in several days.
2. Return if problems.
3. Warm compresses.
4. Put on Bactrim.
DIAGNOSIS: Right thigh abscess with mild cellulitis.
