CHIEF COMPLAINT: Left axillary soft tissue abscess.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old male presented to the emergency department today for evaluation of soft tissue abscess to his left axilla. The patient noted onset of his symptoms two weeks ago. He has noted some gradually increased swelling and pain to the area, to the point where he felt he needed to be seen here in the emergency department. He rates this pain as being constant and throbbing in quality, 7-8/10 in intensity without radiation.
PAST MEDICAL HISTORY: Deafness.
PAST SURGICAL HISTORY: None.
CURRENT MEDICATIONS: None.
ALLERGIES: None.
IMMUNIZATION HISTORY: Not applicable.
SOCIAL HISTORY: The patient is a nonsmoker and denies substance or alcohol abuse.
REVIEW OF SYSTEMS: The patient denies any fever, chills, nausea, vomiting or diarrhea. He denies any upper respiratory symptoms, neck pain, stiffness, chest congestion, cough, chest pain, shortness of breath or wheezing. He denies any numbness, tingling or paresthesias to his left upper extremity or muscle weakness. He does note soft tissue abscess to his left axillary region and notes some fluctuance. The patient denies any purulent drainage from the same. The remainder of his review of systems, otherwise, negative as pertains to chief complaint.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99.6, pulse 100, respirations 18, BP 118/84, and pulse oximetry 96% on room air.
GENERAL: The patient is a well-developed, well-nourished, nontoxic, ambulatory (XX)-year-old male.
INTEGUMENTARY: Focused integumentary exam reveals soft tissue mass to the left axilla, approximately 3 cm in diameter, with visible head. The mass is fluctuant to palpation. There is no evidence of purulent drainage or vascular streaking from the area. Skin is, otherwise, warm and dry to touch with normal tone and turgor.
EXTREMITIES: Full range of motion to all extremities without deficit. The patient exhibits strong distal pulses, brisk capillary refill.
NEUROLOGIC: Reveals no gross motor sensory deficits. The patient is alert, cooperative, and exhibits intact distal sensation in all extremities.
DIAGNOSTIC DATA: None.
EMERGENCY DEPARTMENT COURSE: The patient’s left axillary abscess was prepped with Betadine prior to procedure.
PROCEDURE NOTE: The patient’s left axillary abscess was anesthetized via direct infiltration with approximately 20 mL 1% lidocaine with epinephrine with adequate anesthesia being obtained. The wound area was thoroughly prepped with Betadine prior to being sterilely draped. The soft tissue abscess was subsequently incised with a #11 scalpel. A small amount of mucopurulent discharge was easily palpated from the wound, which was subsequently packed with 1 inch iodoform gauze to maintain a patent incision and facilitate further drainage. The patient tolerated this procedure well without adverse reaction. Polysporin ointment, gauze, and a dressing were applied to the left axilla prior to the patient’s discharge.
MEDICAL DECISION MAKING: We discussed this patient’s case with Dr. John Doe who also evaluated the patient and agreed with the final diagnosis of incision and drainage of a left axillary abscess and the treatment plan that follows.
CONSULTATIONS: None.
IMPRESSION: Incision and drainage to left axillary abscess.
PLAN:
1. Use home Extra Strength Vicodin as needed for pain relief.
2. Follow up with primary care provider in one to two days for removal of packing material as well as wound reevaluation.
3. Return to the emergency department for onset of fever, increased pain, swelling, loss of movement, feeling, and function of left upper extremity or new concerns.
DISPOSITION: The patient is discharged to home in good condition.
