DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: The patient is a (XX)-year-old male coming in complaining of right leg pain.
HISTORY OF PRESENT ILLNESS: The patient states that he was in a fight approximately two weeks ago and scratched up his right lower leg. Since then, he has been going and visiting hot springs. The patient noticed that the site that was previously healing well was now turning red and appeared to be swelling. Pain was continuing to get worse. The patient tried to self-lance and was having more pain now. He also reports limited motion in the right knee due to pain. Pain is 10/10, nonradiating, and constant. Nothing makes it better or worse. Associated limited range of motion in the right knee. No fever. No malaise.
PAST MEDICAL HISTORY: None. No history of steroid use. No history of liver problems.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient admits smoking marijuana. Denies any other drug use such as cocaine or methamphetamines. Denies smoking.
MEDICATIONS: None.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No fever or malaise.
HEENT: Eyes: No change in vision. Ears: No change in hearing. Nose: No epistaxis or rhinorrhea. Mouth: No sore throat.
NECK: No neck stiffness.
CARDIOVASCULAR: No history of cardiac disorders. No chest pain.
RESPIRATORY: No difficulty in breathing. No cough.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, or abdominal pain.
MUSCULOSKELETAL: Swelling below the right knee but not in the right knee. No other joint swelling.
NEUROLOGIC: The patient reports normal sensation and slight numbness in the right foot but states that he can move the right foot without difficulty and feels palpation.
DERMATOLOGIC: Positive swelling below the right knee laterally, getting larger per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 150/86, heart rate 90, respiratory rate 20, O2 sat 99% on room air, and temperature 98.6 orally.
GENERAL APPEARANCE: Alert and oriented x3. No apparent distress. Appears well.
HEENT: Eyes: Pupils equal, round, and reactive to light. Extraocular muscles are intact. Ears: Normal external exam. Nose: No epistaxis or rhinorrhea. Mouth: Normal oropharynx.
NECK: Supple. Nontender.
HEART: Regular rate and rhythm without murmur.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft and nontender to palpation. Positive bowel sounds.
EXTREMITIES: The patient is holding the right knee at 45 degrees flexion. Unable to straighten it due to pain, but the knee itself does not appear swollen. There is no fluctuance of the knee or any other joint.
NEUROLOGIC: The patient reports decreased sensation in the right foot. Otherwise, no focal weakness. No other decreased sensation.
SKIN: There is an area of erythema approximately 8.5 cm x 4.5 cm over the proximal fibula that extends up into the lower portion of the knee but does not cover the knee. There is no palpable fluctuance. There is an area that clearly is where the patient was self-lancing. The area is very taught and excruciatingly tender to the patient.
EMERGENCY DEPARTMENT COURSE: The patient was given morphine 10 mg IV for pain. Blood cultures were sent. X-rays of the tib-fib were obtained as well as the knee, which appear normal. The patient received Toradol. The patient is now able to extend the knee. The patient received Rocephin 1 gram and doxycycline in the ER. The patient received a CBC, which shows 14,200 white count with left shift. BMP is normal.
CONSULTS: Dr. John Doe has come and seen the patient and agrees to I&D the patient, as well as admit the patient for IV antibiotics.
FINAL DIAGNOSIS: Abscess/cellulitis of the right lower leg.
DISPOSITION: Admitted.
