CHIEF COMPLAINT: Wound recheck and packing removal.
HISTORY OF PRESENT ILLNESS: The patient was present in the emergency room two days ago. He had a small abscess drained in his left axilla. Packing was placed. He presents for reevaluation. He has had no complications over the last couple of days. He states that there has been no drainage from the left axillary wound. He has kept it covered since then. He was not given any antibiotics to take. He voices no other physical complaints.
PAST MEDICAL HISTORY: Negative for any chronic diseases. The patient denies hypertension, diabetes, heart, lung, liver and kidney disease.
MEDICATIONS: None currently.
ALLERGIES: None.
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 136/78, pulse 76, respirations 16, and temperature 97.6.
GENERAL: The patient is awake, alert, and oriented, in no acute distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy. No carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES: No clubbing, cyanosis or edema.
SKIN: The patient has a small wound in the left axilla. It appears to be clean, dry, and intact. The packing is in place.
EMERGENCY DEPARTMENT COURSE: The patient presents for packing removal. We did remove the packing. The wound itself was left clean, dry, and intact. There was no evidence of purulent drainage or any bleeding. We placed some Polysporin ointment to the affected area and placed a bandage over it. There was no need to repack at this time. The abscess crater was rather superficial.
DISCHARGE DIAGNOSIS: Wound recheck and packing removal.
PLAN:
1. The patient is advised Polysporin ointment daily.
2. He can keep the bandage on for another couple of days if it does have any draining. After that, he can leave it open to the air.
3. We advised him to clean the area with soap and water.
DISPOSITION: The patient was discharged to home in stable condition.
