DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Bumps and rash on legs.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old male who presents to the emergency department today with a chief complaint of bumps and rash on his legs. The patient states that he was seen here approximately one month ago, at which time he states that he had an abscess noted to his right thumb. The patient, at that time, had an incision and drainage performed. The patient states that he believes it was a staph infection, and he presents today because he states that over the course of this past month, he has developed areas to his upper thighs and a small area in his inguinal region with similar “bumps.” The patient denies any fevers, chills, nausea, vomiting. He denies any history of diabetes. He presents for further evaluation.
PAST MEDICAL HISTORY: Unremarkable.
CURRENT MEDICATIONS: None.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient presents with his wife. The patient is a nonsmoker. He drinks alcohol approximately three times per week. He denies illicit drug use.
REVIEW OF SYSTEMS: See HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 138/94, temperature 98.6, pulse 86, and respirations 18. The patient’s pulse ox is 95% on room air.
GENERAL: The patient is an (XX)-year-old male. He is in no acute distress. He is A&O x3.
SKIN: Natural in color. Capillary refill is brisk. The patient does have erythematous papules and a couple of small pustules noted to the upper anterior thighs as well as a few of these noted to the inguinal region. There are no signs of any abscesses, which needs to be I&D’d at this point. Otherwise, skin is unremarkable.
HEENT: Head is normocephalic and atraumatic. Eyes: EOMs intact bilaterally. Pupils are equal, round, and reactive to light. Ears: TMs and canals are clear. Nose: Nares are patent. Throat: Pharynx patent. Oral mucosa pink and moist.
NECK: Supple. No cervical tenderness or adenopathy. Good full range of motion of the cervical spine.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation in all lung fields.
ABDOMEN: Soft and nontender throughout.
EXTREMITIES: Examination reveals good full range of motion of all joints. Intact neurovascular and sensory exam.
NEUROLOGIC: Cranial nerves II through XII are intact.
EMERGENCY DEPARTMENT COURSE: We discussed the patient with Dr. John Doe. The patient’s physical examination is consistent with folliculitis. We will treat the patient for this and explain to him that if any of these areas were to increase in size with erythema or warmth, possibly, he would need incision and drainage at that time, but at this point, there is no evidence of any secondary abscess.
FINAL DIAGNOSIS: Folliculitis, bilateral legs and inguinal region.
PLAN:
1. Doxycycline 100 mg b.i.d., #20, no refills.
2. Warm compresses.
3. Primary care physician followup.
4. The patient was also given an appointment with Infectious Disease for followup, as the patient is concerned about the recurring outbreaks; although, we did explain to him that this is not uncommon with a history of staph.
5. Return to the ER if worse.
