DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Scalp abscess.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female states she has had a pea-sized area on the back of her scalp for years. She states over the past several weeks she has noticed it increasing in size. She states that today she went across it with a comb after washing her hair and noticed something leaking. She states this has become more painful over the past week or so since it has gotten bigger.
She denies any fever or chills. She denies any nausea, vomiting or diarrhea. The patient denies any other complaints.
PAST MEDICAL HISTORY: Hypertension.
CURRENT MEDICATIONS: Lisinopril and aspirin.
ALLERGIES: Listed in the chart.
SOCIAL HISTORY: The patient denies tobacco or alcohol use. She is married.
REVIEW OF SYSTEMS: Otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 98.6, pulse 84, respirations 20, O2 saturation is 96% on room air, and blood pressure is 112/74.
HEENT: Examination of the posterior aspect of her scalp, in the occiput, shows an obvious protuberance from her scalp that is fluid filled. It is actively draining. When we press on this with a gloved hand, she has a tremendous amount of purulent material with darker cyst material extruding from the area. We were able to completely deflate the cyst. There was a small cavity noted in the remaining portion of the scalp, and this was slightly tender, but there was no surrounding erythema.
EMERGENCY DEPARTMENT COURSE: We explained to the patient that even though the abscess was drained, the cyst cavity still needed to be removed by Dr. John Doe.
IMPRESSION: Infected scalp cyst with spontaneous drainage.
PLAN:
1. The patient is to follow up with Dr. John Doe.
2. The patient was given a prescription for Bactrim to be taken for seven days.
3. The patient is to return as needed.
