CHIEF COMPLAINT: Infected bump on rectum.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female sent to the emergency department today by her OB/GYN who is evaluating her for apparently a cyst removal that she is supposed to have done by laparoscopy next Thursday. The patient reported that she had an infected bump on her behind, and she was sent to the emergency department for evaluation. The patient does report severe, constant pain at that site, which has been going on for the past 3 days; although, she noticed the bump there for the past 7 days. She reports that it is mainly on her right buttock and does not radiate and it gets worse with sitting down and better with lying on her stomach. She has been using Boil-Ease; although, it has done nothing to alleviate this.
PAST MEDICAL HISTORY: Negative.
MEDICATIONS:
1. Boil-Ease.
2. Epsom salt soaks.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies IV drug use. She denies significant alcohol use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Positive as above. All other review of systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 144/86, pulse 82, respirations 18, temperature 97.8, and O2 saturation 98% on room air.
GENERAL: The patient is alert and oriented, in no apparent distress. She is pleasant and conversive in full sentences.
HEENT: Pupils are equally round and briskly reactive to light. Extraocular muscles are intact. Oral mucous membranes are moist without lesions.
NECK: The patient has no noted JVD. No adenopathy is appreciated.
CHEST/LUNGS: The patient’s chest wall is nontender. There is no subcutaneous air. Breath sounds are equal bilaterally. There are no rhonchi, rales or wheezes appreciated to auscultation. There are no focal areas of consolidation.
CARDIOVASCULAR: The patient has a regular rate and rhythm. No murmurs, rubs or gallops are appreciated. Distal pulses are 2+. No carotid bruits appreciated.
ABDOMEN: The patient’s abdomen is completely soft, nontender, and nondistended. Bowel sounds are positive. No organomegaly is appreciated. No masses are appreciated. There are no peritoneal signs. There is no Murphy’s sign.
EXTREMITIES: The patient has no peripheral edema. There is no focal long bone tenderness or deformity.
SKIN: The patient does have an obvious cutaneous abscess on her right buttock, roughly half way down her gluteal crease, which is indurated, extremely tender and is ulcerated over the superior surface to a point that she has a roughly 1.5 cm ulceration, which is draining some purulent material. The surrounding area of induration and erythema is roughly 10 to 15 cm in total diameter. It does not extend to the perianal or perirectal area.
PSYCHIATRIC: The patient is in a normal mental status and has an appropriate affect.
NEUROLOGIC: The patient has 5/5 strength to the upper and lower extremities bilaterally. Sensation is intact throughout. Gait is within normal limits. Deep tendon reflexes are 2+ in all 4 extremities. There are no deficits to the cranial nerves.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. The patient received 10 mg of morphine sulfate IM and roughly 20 minutes later had the area of her abscess anesthetized with 1% lidocaine, which she tolerated well. An 11 blade was then used to incise the area, which was productive of a large amount of purulent drainage. Normal saline was used to irrigate the area after forceps was used to break up any loculations. The area was packed open, and sterile dressing was applied overall. The patient tolerated the procedure well.
IMPRESSION: Cutaneous abscess.
PLAN:
1. The patient was instructed to have her packing removed in 2 days.
2. The patient is to take Bactrim and doxycycline given the fairly extensive aspect of surrounding induration that she has got.
3. Return with worsening fevers, pain or other symptoms.
4. Prescription for a total of 15 Percocet.
DISPOSITION: Home.
