CHIEF COMPLAINT: Cut on foot.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who complains of left foot itching for several months. He noticed some dry skin. He states he does wear boots to work, and he has noticed, over the past couple of days, a small tear to his skin that is slightly painful. The patient denies any trauma, swelling to his foot, numbness or tingling, fevers, chills or sweats. He has not put anything on his foot. He has never had this before. He denies any problems with the right lower extremity.
PAST MEDICAL HISTORY:
1. Depression.
2. Bipolar disorder.
ALLERGIES: None.
MEDICATIONS: Vistaril and Abilify.
REVIEW OF SYSTEMS: The patient is a (XX)-year-old presenting with a cut on his foot. See HPI for review of systems. All other systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 138/86, pulse 84, respirations 18, pulse ox 97% on room air, and temperature 97.6.
GENERAL: Otherwise healthy, well-developed, well-nourished (XX)-year-old male who is alert and oriented x3, in no apparent distress.
EXTREMITIES: On examination of the left lower extremity, specifically of the foot, the patient does have evidence of tinea with some excoriations underneath the fourth toe and a small skin tear. There is no evidence of laceration or surrounding cellulitis or infection. There is no abscess. The patient has good distal pulses. It does not appear to be involving his nails or his foot. It is isolated to between the digits. He has a good distal pulse and full range of motion of the foot.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old presenting with a cut to his foot at this time. This is skin breakdown from tinea. At this time, we have instructed him on proper foot care for this problem, and we will prescribe for him an antifungal cream to apply. He does have primary care for followup.
ASSESSMENT: Tinea pedis.
PLAN:
1. The patient is discharged home with a prescription for ketoconazole 2% cream for tinea pedis, to apply to the affected area once a day for two weeks.
2. He is to keep the areas clean and dry.
3. He is to follow up with a primary care and was given a list of outpatient clinics as well.
4. He was also given a note to return to work on the ninth without restriction.
