CHIEF COMPLAINT: A painful knot on back of the neck.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with a history of hypertension and heart failure, who presents complaining of a painful knot on the back of his neck. He says he noticed it starting 2 days ago as a small area of a pimple. Now, it has become increased in size. He says the pain has also increased to the point where it is difficult for him to turn his head secondary to pain. He denies any fevers. He denies any vomiting or diarrhea. He denies any history of abscesses that needed to be drained in the past, though he did say he had one large area of redness, pain, and swelling on his bottom approximately 2 weeks ago that went away on its own. He has also noted increased thirst over the last couple of weeks.
REVIEW OF SYSTEMS:
CONSTITUTION: The patient denies fevers, chills, dizziness, weakness.
CARDIOVASCULAR: The patient denies chest pain or palpitation.
RESPIRATORY: The patient denies shortness of breath or cough. All other review of systems negative.
PAST MEDICAL AND SURGICAL HISTORY:
1. History of heart failure.
2. Hypertension.
ALLERGIES: He has no known drug allergies.
CURRENT MEDICATIONS:
1. Lasix.
2. Antihypertensive (cannot remember the name of).
3. Aspirin.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: The patient does admit to tobacco use. Admits to ETOH use. Denies any illicit drug use.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 166/102, pulse 84, respiratory rate 21, temperature 97.4. O2 saturation 98% on room air.
GENERAL: Obese male, not in acute distress. Appears comfortable lying in bed.
HEENT: Head is normocephalic. He does have a large area of swelling present at the occipital scalp line that is erythematous and tender to palpation with minimal fluctuance present. Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. No nystagmus noted. No scleral icterus. Oral mucosa moist and pink with no erythema or exudate.
NECK: Supple. No JVD, no cervical lymphadenopathy noted.
LUNGS: Respirations clear to auscultation bilaterally with equal chest wall expansion. CARDIOVASCULAR: Regular rate and rhythm. Normal S1, S2. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, nondistended with positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis or edema noted.
NEUROLOGIC: Cranial nerves II through XII intact. No focal neurologic deficits.
EMERGENCY DEPARTMENT COURSE: The patient was placed in bed. Incision and drainage performed.
PROCEDURE NOTE:
INDICATION: Abscess.
The patient’s area of abscess was prepped using chlorhexidine and anesthetized with 4 mL of 1% lidocaine with epinephrine. After adequate anesthesia was obtained, an 11 scalpel blade was used to incise incision approximately 3 cm in length with a small amount of pus returned. The wound was then explored using sterile hemostats and all loculations were broken up. A packing gauze was placed. The patient tolerated the procedure well. There were no complications to the procedure.
The patient had a fingerstick obtained, which was found to be elevated at 425. With this finding, a urinalysis was obtained which showed no signs of infection, no ketones. A renal panel demonstrated a glucose of 411 with normal potassium and no anion gap. The patient was given a liter of normal saline.
MEDICAL DECISION MAKING: The patient is a middle-aged gentleman, who presents with what appears to be an abscess on the back of his neck. This was drained without difficulty. He did have surrounding cellulitis with this, so the patient will be placed on antibiotics and given pain medication. He did have a fingerstick obtained to evaluate for possibility of diabetes, and he was found to be a new diagnosis of diabetic. A hemoglobin A1c was sent to evaluate where her sugars have been, and he will be started on metformin and followed up by his primary care physician for further diabetic teaching and maintenance of medications.
DIAGNOSIS:
1. Abscess.
2. A new diagnosis diabetes.
PLAN:
1. The patient given prescription for metformin 500 mg p.o. b.i.d.
2. The patient given prescription for Keflex 500 mg p.o. q.i.d. x4 days.
3. The patient given prescription for Bactrim-DS one p.o. b.i.d. x10 days.
4. The patient given prescription for Vicodin 1 p.o. q. 4 p.r.n., total #20.
5. The patient instructed to follow up with Dr. John Doe.
DISPOSITION: The patient was discharged to home in good condition.
