Leg Abscess Emergency Room Transcription Sample Report

CHIEF COMPLAINT: Spider bite.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presents to the emergency department complaining of an abscess to her left lower extremity. She states this has been there for approximately two weeks. She complains of erythema, edema, and pain to the area. The patient rates the pain a 7/10 on 1-10 pain scale, which is worse with palpation. The patient denies any fever or chills. She denies any drainage or bleeding from the abscess. The patient has had previous abscess on her right hip but not on the left leg.

PAST MEDICAL HISTORY: Asthma.

CURRENT MEDICATIONS: Albuterol.

ALLERGIES: None.

SOCIAL HISTORY: Unremarkable.

FAMILY HISTORY: Unremarkable.

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

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 102/64, pulse 84, respirations 18, temperature 98, and O2 sat is 97%.
GENERAL: The patient is alert and oriented x 3, in no acute distress, nontoxic in appearance, ambulatory in the emergency department.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm.
ABDOMEN: Positive bowel sounds all four quadrants, soft, nontender.
EXTREMITIES: The patient has 2+ pulses in all extremities. The patient has approximately 3 x 4 cm abscess noted to the left lower extremity, the lateral aspect of the left mid tib-fib area. The patient has some surrounding erythema but no lymphangitis noted, some induration and fluctuance noted. No active drainage or bleeding noted. Has 2+ dorsalis pedis, posterior tibialis pulse of bilateral lower extremities. No lymphangitis.
NEUROLOGIC: Deep tendon reflexes, sensory, motor intact of the lower extremities.
SKIN: Warm and dry to touch.

EMERGENCY DEPARTMENT COURSE: Procedure Note: The patient was prepped and draped in a sterile fashion. She was anesthetized with 1% lidocaine with epinephrine. An 11 blade was used to make an elliptical incision. A 1/4 inch iodoform was packed in the wound. Dressing was placed over the wound. The patient did receive Vicodin one p.o. for pain as well.

DIAGNOSIS: Left leg abscess, status post incision and drainage.

PLAN:
1.  The patient was given Bactrim DS x10 days, Keflex 500 q.i.d. x10 days, and Vicodin #12 for pain.
2.  Change dressings twice a day.
3.  Warm compresses 20 minutes q. 4 hours.
4.  Follow up in ER in two days for packing removal and wound check.
5.  If symptoms worsen, the patient can return to the emergency department.

DISPOSITION:  Home.

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