CHIEF COMPLAINT: Fever blister.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female, otherwise healthy, who presents to the emergency department complaining of fever blisters to the bilateral corners of her mouth that she noticed last night. The patient has not had a fever blister in the past. She states they are somewhat irritating but not painful. She denies any drainage from the area or crusting over. The patient denies any fever or chills.
PAST MEDICAL HISTORY: Borderline hypertension.
CURRENT MEDICATIONS: None.
ALLERGIES: None.
SOCIAL HISTORY: Positive for tobacco use. Denies alcohol or IV drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 130/82, pulse 66, respirations 16, temperature 98.8, and O2 sat on room air is 100%.
GENERAL: The patient is alert and oriented x3, in no acute distress, nontoxic in appearance, ambulatory in the emergency department.
HEENT: Normocephalic and atraumatic. PERRLA. EOMI. Conjunctivae and sclerae are clear. TMs are clear. Pharynx without erythema or exudate. Mucosa is moist and pink. No sinus tenderness noted. The patient does have a cluster of 1 mm vesicular lesions noted to both corners of her mouth. There is no crusting over noted. There is no drainage noted from the areas. There is no lip swelling or erythema noted.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE: The patient is a (XX)-year-old female with what appears to be oral herpetic infection. We will place the patient on some antiretrovirals and refer her to family physician for followup.
DIAGNOSIS: Oral herpes.
PLAN:
1. The patient was given acyclovir 400 t.i.d. x7 days.
2. She was given a clinic list for followup.
3. If fever, chills, lip swelling or worse, the patient can return to the emergency department.
DISPOSITION: The patient was discharged in stable condition.
