CHIEF COMPLAINT: Left leg infection.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male who has been seen here in the past for left leg infection. He presents today stating that he is concerned it has not gone away because the prescription that he had for Bactrim he could not afford. The patient has been taking it intermittently over the past couple of weeks. He has been using peroxide. He is not sure that is helping. He thinks it is too wet. He denies any itching. He states his symptoms actually have not changed. They have not gotten worse or better. The patient denies fevers, chills, streaking or groin pain. He states this initially started from getting stabbed in the leg from a barbed wire fence.
PAST MEDICAL HISTORY: Psychiatric disorder.
MEDICATIONS: Valium and fluoxetine.
ALLERGIES: None.
SOCIAL HISTORY: The patient is a half-pack-per-day smoker. He drinks a pint daily. The patient denies drug use.
REVIEW OF SYSTEMS: The patient is a (XX)-year-old presenting with leg infection. See HPI for review of systems. All other systems are negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 118/80, pulse 76, respirations 18, temperature 98.4, and O2 sat is 99% on room air.
GENERAL: Otherwise healthy, well-developed, well-nourished (XX)-year-old male who is alert and oriented x3, nontoxic, in no apparent distress.
EXTREMITIES: On examination of the patient’s left inner thigh, the patient does have a reddened area that appears to be more excoriated. He has no lymphangitic streaking. He has no abscess. It is not tender. There is no active bleeding or drainage. At this time, it appears to be more of a superficial excoriated wound as opposed to a soft tissue infection. He has full range of motion and is ambulatory without complication.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old presenting with leg infection. At this point, it seems to be more superficial secondary to excoriation. At this point, we do not feel like he will benefit from antibiotics but rather topical antibiotic cream and wound care. He is not a diabetic. We will discharge him home at this time with outpatient followup.
ASSESSMENT: Left leg infection.
PLAN:
1. Discharge the patient home.
2. The patient is to wash the area twice a day with soap and water, dry well.
3. The patient is to apply antibiotic ointment and a bandage.
4. He is to follow up with his primary care.
5. Return if worse.
