CHIEF COMPLAINT: Insect bite, left leg.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Caucasian female, gravida 2, para 1, currently approximately 5 months pregnant, who presented to the ER with complaints of bug bite that she noticed to her left lower extremity earlier today. The patient reports minimal itching and a constant soreness associated with these red swollen areas to her left lower leg. The patient currently rates her pain as 4/10 in severity. She has not required any medication at home for her pain. She denies paresthesias, numbness, coldness, loss of range of motion or weakness in the extremity. Otherwise, the patient has no complaints.
PAST MEDICAL HISTORY:
1. Asthma.
2. Gravida 2, para 1, currently 5 months pregnant.
MEDICATIONS:
1. Prenatal vitamins.
2. Albuterol p.r.n.
ALLERGIES: None.
FAMILY HISTORY: None elicited.
SOCIAL HISTORY: The patient denies tobacco, alcohol or illicit drug abuse.
REVIEW OF SYSTEMS: As stated above in the HPI significant for red, swollen areas associated with mild pain to the left lower leg. The patient has otherwise been well without fevers, chills, nausea, vomiting, abdominal pain, changes in urinary or bowel habits, polyuria, polydipsia, heat or cold intolerance, fatigue or recent weight changes. Further review is otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 116/72, pulse 84, respirations 20, temperature 98.6, pulse ox on room air is 98%.
GENERAL: This is a well-developed, well-nourished Caucasian female, in no acute distress. She is alert and oriented x3.
HEENT: Normocephalic, atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Mucous membranes are pink and moist.
NECK: Supple.
CHEST: Respirations are easy, nonlabored.
LUNGS: Clear to auscultation bilaterally without wheezes, rales or rhonchi.
HEART: Regular rate and rhythm without murmur, rub or gallop.
EXTREMITIES: No cyanosis, edema or clubbing. There is no calf tenderness or cords appreciated. DP and PT pulses are present and equal bilaterally with brisk capillary refill in all 5 digits.
SKIN: The patient has 4 areas on her left lower leg, approximately the size of a half dollar. These areas are reddened, edematous and slightly indurated. There is no fluctuance or evidence of abscess. The areas are located at the posterior calf, posterior ankle and posterior heel. There is no obvious puncture associated. No lymphangitic streaking. There is otherwise no rash noted. Skin is otherwise warm, dry and intact.
EMERGENCY DEPARTMENT COURSE: The patient was given Benadryl 25 mg p.o.
DIAGNOSIS: Left leg insect bites. At this time, it is felt that the red and swollen areas are local inflammatory rash and as a result of the bite. It does not appear to be cellulitic at this time; however, the patient will be treated conservatively.
PLAN:
1. Tylenol as needed for pain.
2. The patient is given a prescription for amoxicillin to take should her symptoms worsen, including worsening redness, worsening pain or unresolved swelling. She is to wait 2 days and then if her symptoms have not improved, she is to start the antibiotics.
3. The patient is to follow up with her primary care physician.
4. Return to the ER for fever, red streaking up the leg or other worsening symptoms.
5. The patient is to take over-the-counter Benadryl as needed for itching.
DISPOSITION: The patient is discharged home in good condition.
