CHIEF COMPLAINT: Lump in left armpit.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presented to the emergency department with the above complaint. The patient states this first started approximately 10 days ago and states that she saw her primary doctor. The patient states at that time her doctor put her on Bactrim for 14 days; however, he did tell her she may need to have this incised and drained. The patient does state since the visit with the doctor, the lump has gotten smaller; however, she still has some pain. The patient does state recently her significant other had six that were drained. The patient denies any fever or chills associated with this. The patient denies any nausea, vomiting or purulent drainage. The patient denies any recent hospitalizations or incarcerations and states that her boyfriend has not been incarcerated either. The patient has no history of abscesses in the past.
PAST MEDICAL HISTORY: Heart murmur.
CURRENT MEDICATIONS: Ibuprofen and Bactrim.
ALLERGIES: IVP DYE.
SOCIAL HISTORY: The patient smokes half pack of cigarettes a day and denies use of alcohol, illicit or IV drugs.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As stated above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 124/72, pulse 84, respirations 18, temperature 98.4, and O2 saturation 98% on room air.
GENERAL: This is a well-developed, well-nourished (XX)-year-old female who is alert and oriented x3 and appears to be in no acute distress. The patient is cooperative, communicates well, and was ambulatory into the emergency department.
LUNGS: Clear to auscultation bilaterally. No wheezing, rales or rhonchi noted.
HEART: Regular rate and rhythm. No murmur, rubs or gallops noted.
EXTREMITIES: Distal pulses 2+ bilaterally. The patient has full range of motion of all extremities. Sensation is intact. Muscle strength is appropriate and equal bilaterally. Upon further examination of the patient’s left upper extremity, she has 2+ radial and ulnar pulses with intact radial, median, and ulnar nerves. The patient has full range of motion of that extremity. The patient does have an approximately 1.5 to 2 cm nodule noted in the left axilla with palpation. This is significantly tender with palpation; however, we do not note any significant induration or fluctuance. The patient has a very light erythema to the area. There are no breaks in the skin. There are no other palpable masses.
NEUROLOGIC: Cranial nerves II-XII are intact. DTRs 2+ bilaterally of both upper and lower extremities. Muscle strength 5/5 of all extremities. No focal deficits noted.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE: The patient was examined.
PROCEDURE NOTE: The patient’s lump was anesthetized with 1% lidocaine with epinephrine using approximately 4 mL. Then, an 18-gauge needle was injected into the mass, and no purulent drainage was aspirated. We did not note any purulent drainage with pressure of that area either. The area was then cleaned, and a sterile dressing was applied. The patient tolerated this well.
IMPRESSION: This is a (XX)-year-old female who presents to the emergency department with a left axillary cellulitis. Upon examination, there was no significant fluctuance to palpation. Therefore, we did not open up the abscessed area. We did use an 18-gauge needle, and no purulent drainage was aspirated. At this time, we do feel the patient is stable for discharge home, and we will add on Keflex with her Bactrim. The patient was also instructed to use warm compresses to the area.
DIAGNOSIS: Left axillary cellulitis.
PLAN:
1. Continue Bactrim as prescribed by PCP.
2. Keflex 500 mg.
3. Warm compresses to the area at least three times a day.
4. Follow up with PCP.
5. Return for any worsening symptoms.
DISPOSITION: The patient was discharged to home in stable condition.
