CHIEF COMPLAINT: Wound recheck and packing removal.
HISTORY OF PRESENT ILLNESS: The patient presented to the emergency room two days ago for an abscess in the left groin area. It was incised and drained and packing was placed. She tolerated the procedure fine. She has been doing well in the two days in between ER visits. She has been taking the antibiotics given to her at a previous emergency room visit.
PAST MEDICAL HISTORY: Significant for non-insulin-dependent diabetes, hypercholesterolemia, and hypertension.
MEDICATIONS:
1. Augmentin.
2. Tylenol.
3. Advil.
4. Vytorin.
5. Actos.
6. Diovan.
7. Fluphenazine.
8. Diphenhydramine.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies alcohol, tobacco or illicit drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As mentioned, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 106/72, pulse 98, respirations 20, and temperature 97.8.
GENERAL: The patient is awake, alert, and oriented, in no acute distress.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal. Sensation is grossly intact.
INTEGUMENT: The patient has an abscess that has been incised and drained in her left groin. Packing is present at the time of exam.
EMERGENCY DEPARTMENT COURSE: This patient presented for packing removal and wound recheck. Upon evaluation, her wound was clean, dry, and intact. There is no evidence of any purulent drainage. There is no bleeding. The packing was removed, and a bandage was replaced. We did not see any reason to place any more packing. There is about 6 inches in the wound itself. She does have a followup already scheduled with her primary care physician. She does have Augmentin to take for the infectious process, which she states she has been taking and will continue to take until finished. The pain is well controlled with over-the-counter pain medications.
DIAGNOSIS: Packing removal and wound recheck.
DISPOSITION: The patient was discharged to home in stable condition.
