DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Swelling and pain to the second and fifth digit of her right hand for two weeks.
HISTORY OF PRESENT ILLNESS: The patient states that she has been house-sitting and has been doing a lot of cleaning, so she has had some exposures to her hand. She also said that she thought she might have been getting an infection, and she has been trying to express pus or liquid from the wounds but has been unable to do. The patient denies any fevers. She denies any traumatic injury to her hand. She is right-hand dominant.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: The patient is right-hand dominant. She works as a housekeeper. She denies any tobacco, alcohol or drugs.
REVIEW OF SYSTEMS: MUSCULOSKELETAL: As per HPI. CONSTITUTIONAL: As per HPI. Otherwise, 10-point review of systems was done and is negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 134/88, heart rate 78, respiratory rate 16, temp 36.6, and saturation 99% on room air, which is normal.
GENERAL: The patient is well appearing and nontoxic. She is alert and oriented x4 with a GCS of 15.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular muscles are intact. Oropharynx is benign with moist mucous membranes.
NECK: Supple. Full range of motion. No meningismus.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
EXTREMITIES: Particularly, the right hand, the patient does have swelling at the base of the nail bed on the second digit of the right hand. She also has some swelling of the finger of the fifth digit as well. She has full range of motion at all joints. Her sensation is intact distally. Her skin is intact. Her radial and ulnar pulses are 2+. There is no fluctuance over these areas.
PSYCHIATRIC: Normal affect, cooperative to the examination.
NEUROLOGIC: The patient is moving all extremities, feeling all extremities with no focal deficits.
EMERGENCY DEPARTMENT COURSE: The patient was seen and examined by myself. She was complaining of some tingling, paresthesias in her hand as well, so an Accu-Chek was done, which was 108, essentially within normal limits. The patient’s fingers were examined. We did consider that this could be a paronychia, and we do feel that likely it was a paronychia that actually self-drained. There was no fluctuance. There was no tenderness. There was no erythema, and we did not feel that it needed an incision and drainage at this time. However, as the patient has very mild erythema over the fifth digit and some swelling, we did consider that she could have a cellulitis and so we recommended coverage with a short course of antibiotics with Keflex and follow up for a wound check in two days. The patient has been instructed to return for new or worsening symptoms.
DISPOSITION AND DISCHARGE CONDITION: Home, in stable condition.
DIAGNOSIS: Paronychia with cellulitis.
