CHIEF COMPLAINT: Spot on the ear.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who comes in via private vehicle. He states that two days ago he had what he describes as a small bump just anterior to his left ear. He states that over the last few days, this has expanded in size, and he is here for further evaluation. He states he did have a problem with “sores” in the past but not quite as big as the one he is complaining of currently.
The patient has a history of hepatitis C and, per the records, delusional parasitosis. He is denying any manipulation or picking to the area but does seem to be picking at other spots on his skin during history. He is denying any discharge or bleeding from his inner ear. He is denying any decreased hearing and has no pain over the site. He has had no fevers, chills, nausea or vomiting. He is denying any headache or dizziness. He is denying any hallucinations on examination.
PAST MEDICAL HISTORY: Hepatitis C, reflux. Per the records, he has a psychiatric history, but the patient denies this currently.
PAST SURGICAL HISTORY: The patient denies.
MEDICATIONS: Prilosec daily p.r.n. and ibuprofen p.r.n.
ALLERGIES: NONE.
SOCIAL HISTORY: The patient admits to smoking and denies any alcohol or drug use.
REVIEW OF SYSTEMS: Remaining review of systems reviewed and negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 35.6, pulse 86, respiratory rate 18, blood pressure 144/82, weight 168 pounds, height 5 feet 6 inches, and oxygen saturation 95% on room air.
GENERAL: The patient is alert, and he is oriented to where he is. He appears nontoxic. He is ambulatory with a steady gait.
HEENT: Head: Upon inspection, there are some small pinpoint areas of erythema and excoriation noted, but focused just anterior to his left ear shows an area approximately 6 cm oval that appears to be erythematous and has some dried blood surrounding the area but is not actively bleeding or having any discharge. There is some surrounding scab formation with honey-colored crust appearance, particularly over the inferior aspect. There are no sores or open wound to the posterior inner aspect of the ear. Note that there is no involvement to the forehead or the top of the scalp. His excoriations do not appear to be in a dermatomal distribution. Eyes: PERRL. Extraocular movements are intact. Sclerae and conjunctivae are clear. There is no injection, no tenderness over the globes. Ears: There is some cerumen impaction to the left ear, so we are unable to visualize the TM; however, there is no bleeding, discharge. There is no erythema or exudates of external canals. The internal ear canal appears to be intact. The surrounding pinna and tragus have no ulcers or sores and appeared to be having skin intact throughout. There is no tenderness to manipulation of the ear. The right ear TM is somewhat visible and appears to be intact and again no erythema, exudate, drainage, bleeding to the right ear. Nose: Nares are patent, no congestion. There is no tenderness. Oropharynx: Mucous membranes are moist and pink. No erythema or exudate of pharynx. No ulcers in the mucosal membranes.
NECK: Supple, no lymphadenopathy. He has full range of motion.
CHEST: Clear and equal breath sounds throughout.
HEART: Regular rate and rhythm.
NEUROLOGIC: The patient is alert and oriented. Cranial nerves II through XII are grossly intact.
SKIN: Again, there are randomly dispersed areas of small macules and papules that appear to be in various stages of healing where the patient seems to pick at them.
EMERGENCY DEPARTMENT COURSE: We did clean the wound just anterior to the left ear. We applied bacitracin and covered with a large Band-Aid. He was given Keflex 500 mg p.o. x2 and Bactrim DS 2 p.o.
ASSESSMENT:
1. Intertrigo to the left face.
2. History of hepatitis C.
3. History of delusional parasitosis.
PLAN:
1. Discharge the patient home.
2. Bactrim DS, Keflex, Atarax. Wash daily. Keep clean and dry. He is encouraged to use over-the-counter Neosporin ointment and keep it covered with a Band-Aid.
3. Return to the emergency room for any fever greater than 38, worsening signs and symptoms, increased redness, swelling, decreased hearing loss or any further concerns.
4. The patient is encouraged to follow up with his PCP this week to schedule an appointment.
CONDITION ON DISPOSITION: Stable.
