CHIEF COMPLAINT: Swollen right foot.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female with a past medical history significant for hepatitis C, who presents to the emergency department because the top of her right foot is red, swollen, and it has been that way for the last three days. The patient says that the pain level is about a 10/10 and is located on the top of the right foot. She explains that standing provokes pain. She denies that anything relieves the pain or that the pain radiates. She reports that the pain is of a throbbing quality. The patient reports she may have had a spider bite on the top of her right foot. Otherwise, the patient denies any other events surrounding injury to her foot. The patient denies any fevers, chills or night sweats. She denies any other symptoms.
PAST MEDICAL HISTORY: Significant for hepatitis C.
MEDICATIONS: None.
ALLERGIES: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient reports that she smokes one and a half packs of cigarettes a day. The patient denies alcohol use and denies drug use.
REVIEW OF SYSTEMS: As per HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 104/72, pulse 84, respiratory rate 20, temperature 98.4, and oxygen saturation 98% on room air.
GENERAL: The patient is able to speak in full sentences and is not using accessory muscles for respiration and appears to be in no state of acute distress.
HEENT: Eyes: No scleral icterus or conjunctival pallor. ENT: Mucous membranes are moist. No tonsillar enlargement, erythema or exudate.
NECK: No lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: S1, S2 are present. No murmurs, gallops or rubs.
ABDOMEN: Soft, nontender, and nondistended. Bowel sounds are present in all four quadrants.
SKIN: Examination of the skin reveals an approximately quarter size diameter, elevated, erythematous, warm area located at the mid foot between the first and second digits of the right foot. There is no active drainage from the area. The area is exquisitely tender to palpation. There is excoriation noted in the middle of the lesion. When asked about this, the patient explained that she tried to lance the lesion herself a couple of days prior.
LABORATORY DATA AND RADIOLOGY: None.
PROCEDURE: Incision and drainage.
INDICATION: Abscess.
PROCEDURE DETAILS: After the patient was explained the details of the procedure, the area was anesthetized with 1% lidocaine and cleaned with a surgical scrub. After appropriate anesthesia was administered, the area was lanceted, and approximately 10 mL of purulent fluid was expelled from the area. The area was then subsequently irrigated thoroughly and then subsequently packed. The patient tolerated the procedure relatively well.
EMERGENCY DEPARTMENT COURSE AND TREATMENT: The patient was seen and evaluated. The patient was given Percocet and morphine in the emergency department and had her abscess incised and drained.
IMPRESSION: Right foot abscess.
PLAN:
1. The patient is discharged home with a prescription for Bactrim Double Strength one p.o. b.i.d. for 10 days. She is given a total of 20 with no refills. She is also given a prescription for doxycycline 100 mg p.o. bid. She was given a total of 20 with no refills. She was given each antibiotic to take for 10 days. She was also given a prescription for Percocet 5/325 one to two p.o. q 6 hours p.r.n. pain. She was given a total of 30 with no refills.
2. She is told to return in two days for packing removal and wound recheck.
DISPOSITION: Discharged to home in good condition.
