DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Right knee abscess.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who presents to the emergency department with concerns regarding abscess to his right knee, and it has been worsening over the last three to four days. The patient became concerned when he noticed redness spreading above his right knee. The patient denies any joint swelling and has normal flexion, extension of his knee. The patient has had subjective fevers but has not measured his temperature. The patient does have a prior history of abscess in the past. The patient works at a job that requires him to be frequently on his knees.
PAST MEDICAL HISTORY: Cellulitis and history of abscess.
MEDICATIONS: None.
ALLERGIES: NKDA.
REVIEW OF SYSTEMS: INTEGUMENT AND CONSTITUTIONAL: As above. All other 10-point systems reviewed are negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 36.6, blood pressure 126/76, pulse 72, respirations 18 and nonlabored, and pulse ox 98%.
GENERAL APPEARANCE: The patient is awake, alert, well appearing, nontoxic, resting comfortably, in absolutely no apparent distress.
EXTREMITIES: The patient has normal flexion and extension of his right knee with no worsening pain and normal range of motion. There is no joint swelling or warmth to the touch.
SKIN: There is a small, approximately 1.5 cm area of fluctuance with surrounding erythema over his right knee.
NEUROLOGIC: The patient is awake, alert, and grossly nonfocal.
DIAGNOSTIC DATA: None indicated.
EMERGENCY DEPARTMENT COURSE: The patient’s condition remained stable during ED stay. The patient declined any analgesics, stating he was comfortable. The patient was medicated with Ancef 1 g IM and Bactrim 1 tab p.o.
PROCEDURE NOTE: Using sterile technique, the patient’s right knee was prepped and draped in the normal sterile fashion. Local anesthesia was achieved using approximately 1.5 mL of 2% lidocaine. The abscess was then incised using a 11 scalpel blade. Approximately 3 to 4 mL of purulent drainage was expressed. The abscess was fairly small, and therefore, no packing was placed. The patient tolerated the procedure well with no complications.
IMPRESSION:
1. Right knee abscess, status post incision and drainage.
2. Acute cellulitis.
DISPOSITION: Home.
PLAN:
1. Return to the emergency department in 48 hours for wound check.
2. The patient was prescribed Keflex and Bactrim.
3. Norco p.r.n. breakthrough pain and given driving precautions.
