CHIEF COMPLAINT: Rash on thumb and chin.
HISTORY OF PRESENT ILLNESS: The patient presents today with a one-week history of swelling of his right thumb. He states that he does have full range of motion; although, it does cause him to have pain. He has noticed generalized swelling and worsening of the eczema on the fingers. He rates his pain as 9/10. It is worse with moving. It is better with massaging, and it radiates to his elbow, and he also states that he has had swelling on his chin, which has been present approximately four days. He has noticed that it will be fluctuant, and he fears that because he has never had anything previous like this before. He has some swelling, surrounding erythema. He also has a similar lesion on his arm, which is now healing. He has never had anything like this previous.
PAST MEDICAL HISTORY: Significant for asthma and seizure disorder.
ALLERGIES: Penicillin, which causes a rash.
MEDICATIONS: Trileptal.
SOCIAL HISTORY: The patient used tobacco up until (XX) days ago. He admits occasional alcohol use, and he used to use marijuana.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: The patient denies any fever, chills, chest pain or shortness of breath. He does have the rash on his arm as well as swelling in his thumb. All other systems are reviewed and are negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Respirations 16, pulse 80, BP 154/110, and O2 saturation 90% on room air.
GENERAL: The patient is a well-developed, well-nourished Hispanic male in no acute distress.
HEENT: Extraocular muscles are intact. Pupils are equal, round, and reactive to light. Nares are patent. No erythema. Mucous membranes are moist.
NECK: Supple with no JVD.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
EXTREMITIES: He has a slightly swollen thumb, right hand. There is minimal erythema around the tip. There is a small area on the palmar surface of the thumb, over the pad, which does feel slightly fluctuant; otherwise, he has a full range of motion.
NEUROLOGIC: Sensation is intact.
SKIN: The patient has scaling on his finger of his right hand. He also has an area on his thumb, which is approximately 2 x 2 cm. There is a small area of healing scab, but this lesion is previously opened.
PSYCHIATRIC: The patient is cooperative. Appropriate mood and affect.
EMERGENCY DEPARTMENT COURSE: The patient was evaluated. Procedures were performed as below. He was discharged home with Bactrim, doxycycline, and hydrocortisone.
PROCEDURES PERFORMED:
1. I and D of facial abscess: The patient was prepped and draped in the sterile fashion. Approximately 2 mL of 1% lidocaine without epinephrine was infiltrated. The previously opened area was unroofed. A large amount of purulent material was expressed, and forceps were used to break up loculations. Bandage was applied. The patient tolerated the procedure well with no complications.
2. I and D of thumb lesion: The patient was prepped and draped in the sterile fashion. A digital block was performed on the thumb using approximately 3 mL of 1% lidocaine without epinephrine. After anesthesia was achieved, a 1 cm incision was made on the palmar surface of the pad of the right thumb. No purulent material was expressed. There was sanguineous material that was expressed. Sterile bandage was applied. The patient tolerated the procedure well with no complications.
MEDICAL DECISION MAKING: The patient presented today with a chief complaint of swelling and abscesses. He has multiple abscesses. We do believe that he is at high risk for MRSA. We will treat him with Bactrim and doxycycline. As far his facial abscess, there is a large fluctuant area, and therefore, I and D was performed. A large amount of purulent material was expressed.
Otherwise, the patient had some swelling of his thumb. He did have full range of motion. He had no evidence of a felon. This was excised, and there was sanguineous material that was expressed; although, this was not purulent. Therefore, this may be consistent with cellulitis. We believe, because he does have eczema, this may have put him at increased risk for this. At this time, the patient will be taking Bactrim and doxycycline. We will also give him hydrocortisone for this thumb. Otherwise, he has no other lesions that are evident.
CLINICAL IMPRESSION:
1. Facial abscess.
2. Right thumb cellulitis.
3. Eczema.
PLAN:
1. The patient will be discharged with a two-week course of Bactrim and doxycycline.
2. Use hot pads four times a day.
3. Return for any worsening swelling, pain, fever, redness or any other concerns.
