DATE OF ADMISSION: MM/DD/YYYY
DIAGNOSES: Acute cellulitis, right elbow, and acute bursitis of the right elbow.
HISTORY OF PRESENT ILLNESS: This patient is a (XX)-year-old Hispanic male with a past medical history of hypertension, hyperlipidemia, and tennis elbow. He was complaining of swelling and tenderness and a golf ball-like mass in the right elbow for several weeks before he came to the walk-in clinic on Monday. He also complained of a scratch and exudative material that was coming out or pus coming out of the elbow wound at the tip of the olecranon bursa. He had some fever and chills over the past few days before coming into the emergency room. He denies any history of gout. His medication was Accupril and Pravachol. In the emergency room, we tapped his joint and we got about 20 to 25 mL of straw-colored, clear fluid, slightly opaque, and was sent for culture, cell count, and crystals. He was also given Keflex at that time. He was sent home and asked to use local NSAID, painkiller, and Keflex. The next day, the patient called and came to our office with increasing swelling, pain, and tenderness after the drainage. Our exam revealed spreading of the swelling, erythema, heat, and tenderness of the forearm and the upper arm, especially the medial part of the upper arm, and we suspected thrombophlebitis, so we sent him to the hospital to be admitted for IV antibiotics and ultrasound of the upper arm. The patient came to the emergency room and was admitted for that. He was cultured. He got an ultrasound and was given antibiotics.
PAST MEDICAL HISTORY: As mentioned above, hypertension, hypercholesterolemia, tennis elbow, and no gout.
SOCIAL HISTORY: The patient smoked one pack per day for many years. Alcohol: None.
FAMILY HISTORY: Lung cancer and history of Alzheimer’s. No CAD. No hypertension. No gout.
REVIEW OF SYSTEMS: As mentioned above, pain, swelling, erythema, fever, and chills; other than that, none.
ALLERGIES: None.
MEDICATIONS: Pravachol and Accupril.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is alert, awake, and oriented.
VITAL SIGNS: Initially, temperature 98.2, pulse 86, respiration 18, blood pressure 124/74, and O2 saturations on room air 100%. The patient is about 5 feet 6 inches and about 142 pounds.
HEENT: Head exam normal. Eyes, ears, nose, and throat are normal.
NECK: Supple. No JVD.
CHEST: Clear.
LUNGS: Good air exchange.
HEART: S1 and S2, regular. No murmur.
ABDOMEN: Soft, benign, and nontender.
EXTREMITIES: Revealed large, solid, soft tissue swelling of the olecranon bursa on the right elbow with erythema, heat, tenderness, and edema of the soft tissues of the dorsum of the right forearm, right hand, and right upper arm in the medial aspect with tenderness and intact pulses and intact range of motion. The joint itself appears to be intact with normal range of motion.
LABORATORY DATA ON ADMISSION: White blood cell count was 20,200. H&H normal. There was shift to the left with 75% neutrophils and 1 band. PT and PTT normal. Chem-7 essentially normal. Chloride 102 and CO2 of 30. Random blood sugar was 110 and the rest of the chemistry was normal. A chest x-ray was taken also as a baseline and that was normal. Ultrasound done in the emergency room showed he has no DVT, so he was cultured and given IV antibiotic, mainly Keflex, and we are waiting for culture results.
The patient will get also an ID consult and orthopedic consult, and we will try to contact his primary doctor.
