CHIEF COMPLAINT: Bump on face.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who presents to the emergency department complaining of what he describes as a “bump” on the face that he feels may have started off as an ingrown hair. It has been there over two days. He rates his pain as a 3/10 on a 1-10 scale. It has not been draining any purulent drainage. He is not diabetic. He has had no recent incarcerations, hospitalizations. No other sick contacts. He has never had a lesion like this before. He is concerned this has not been draining and has become more and more painful and red and swollen. He denies any other fevers, chills, cough, congestion, chest pain, shortness of breath, abdominal pain, nausea or vomiting. He does not have a regular primary care physician that he can see.
PAST MEDICAL HISTORY: None.
MEDICATIONS: None.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He denies tobacco use. Does smoke marijuana and socially drinks alcohol.
REVIEW OF SYSTEMS: As stated in the HPI. All other pertinent review of systems are otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, BP 140/92, pulse 92, respirations 18, and O2 sat 100% on room air.
GENERAL: The patient is a well-developed, well-nourished Hispanic male who is alert and oriented. He is in no acute distress.
HEENT: Head is normocephalic and atraumatic. The patient’s eyes are PERRLA, EOMI. Nares patent. Nasal mucosa is moist. Oropharynx is clear. Uvula is midline. He has no diffuse facial edema, no asymmetry; although, the patient does have one localized area of edema just essentially in the buccal space. It is 2 cm in diameter, and it is an erythematous, raised, indurated area with one central area of fluctuance. No lymphangitic streaking.
NECK: Supple. He does have a left-sided cervical adenopathy.
HEART: Regular rate and rhythm, equal S1, S2.
LUNGS: Clear to auscultation bilaterally.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING: After history and physical, the patient’s nursing notes were reviewed. At this time, the patient does appear to have a left facial abscess requiring I&D procedure. We will send him home with Bactrim and doxycycline as well as Vicodin for pain and have him follow up with the Surgery Clinic or return in two to three days for packing removal. The patient did tolerate the procedure well without any complication and was discharged home. He was not diabetic; no history of this in the past. Although his MRSA risk factors are low, we did empirically treat him for MRSA.
PROCEDURE NOTE: The patient’s left-sided facial abscess was anesthetized with 2 mL of 1% plain lidocaine. It was prepped with Betadine and draped in sterile fashion, and an 18 gauge needle was used to attempt a needle aspiration. We were able to extract approximately 2 mL of purulent drainage and therefore made 0.5 cm linear incision with an 11 blade, a total of 4-5 mL of purulent drainage were expressed. Hemostats were used to break loculations and then a quarter inch plain packing gauze was placed in the wound well and a dry sterile dressing. He tolerated the procedure well without any complications.
DISPOSITION: Stable, discharged home.
DIAGNOSIS: Left facial abscess, status post incision and drainage.
PLAN:
1. Bactrim DS b.i.d. for seven days.
2. Doxycycline 100 mg b.i.d. for seven days.
3. Vicodin #12 as needed for pain.
4. Follow up with Surgical Clinic in two to three days for packing removal.
5. Otherwise, return for signs of infection.
