CHIEF COMPLAINT:
Infected border, great toe.
HISTORY OF PRESENT ILLNESS:
The patient is a (XX)-year-old male who for the last 4 days has had pain in the left great toe. He states that he tried to get part of it out himself but was unsuccessful. The patient states that his toe has been red and swollen with a small amount of drainage as well. He has had history of finger paronychia. The patient denies fever.
PAST MEDICAL HISTORY:
Negative.
ALLERGIES:
No known drug allergies.
CURRENT MEDICATIONS:
None.
REVIEW OF SYSTEMS:
See HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 122/66, temperature 98.2, pulse 64, respirations 18, pulse ox 98%.
GENERAL: The patient is a (XX)-year-old male in no acute distress. He is alert, oriented and cooperative with examination.
EXTREMITIES: The patient has normal range motion of his left lower extremity. Along the medial border of the left great toe, the patient has what appears to be an infected ingrown nail. There is really no evidence of acute cellulitis. There was some dried drainage noted on top. Sensation was intact. Capillary refill less than 2 seconds. Distal pulses are intact.
EMERGENCY DEPARTMENT COURSE:
Recommended to the patient that a wedge excision be performed to which he was in agreement. The left great toe was anesthetized in a digital block fashion utilizing a total of 4 mL of 2% lidocaine plain mixed with 0.5% bupivacaine. After the area was anesthetized, a wedge excision was performed and a Polysporin and dry dressing was placed.
IMPRESSION:
Left great toe ingrown nail.
PLAN:
1. Warm soapy soaks.
2. Polysporin ointment several times a day.
3. Ibuprofen p.r.n.
4. Keflex 500 mg, #28 was given.
5. Follow up with his doctor in 7 days if no better.
6. Return if worse.
DISPOSITION:
The patient was treated and released in stable condition.
Sample #2
CHIEF COMPLAINT:
Infected right great toe.
HISTORY OF PRESENT ILLNESS:
This is a (XX)-year-old male patient who was brought in with a complaint of redness and swelling to the right great toe x5 days, also some swelling in the right inner thigh and what appears to be an abscess in the right gluteal. The patient complains of pain and tenderness over the right upper and inner thigh. There is no sign of erythema or edema, no swelling. They are not sure how long the upper inner thigh has been this way. They just noticed it today. The abscess in the right gluteal has been there for 3 days. The patient has had no fever or chills, no nausea or vomiting. Nursing notes reviewed.
REVIEW OF SYSTEMS:
No fever or chills. Review of systems, otherwise, negative.
PAST MEDICAL HISTORY:
The patient is, otherwise, in good health.
SOCIAL HISTORY:
Not applicable.
ALLERGIES:
None.
CURRENT MEDICATIONS:
None.
IMMUNIZATIONS:
Up-to-date.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.4, pulse 104, respirations 22, blood pressure 112/70 and pulse ox 99% on room air.
GENERAL APPEARANCE: This is a (XX)-year-old male patient who is awake and alert, sitting on the gurney, resting comfortably, nontoxic.
EXTREMITIES: The patient has an abscess in the right gluteal, approximately the size of a quarter, mild erythema with a pustular center, very, very mild induration in the surrounding area. The right upper inner thigh has no erythema, edema or ecchymosis. There is an area of approximately 3.5 cm of induration, very tender with palpation. The right great toe has obvious signs of paronychia, erythematous, edematous with pustular center. No streaking. The remainder of the skin is warm, dry and intact.
DIAGNOSTIC TESTS:
None.
PROCEDURE:
I&D was performed on the right great toe and right gluteal. Both areas were prepped. After local anesthesia, the right great toe was anesthetized with a digital block with bupivacaine without epinephrine. The right gluteal was anesthetized with bupivacaine with epinephrine. Both areas were incised and drained. The right great toe had copious amounts of purulent discharge. The right gluteal had a scant amount of purulent discharge. Both wounds were then packed with quarter inch iodoform and cleansed and dressed. There were no complications.
CONSULTATIONS:
None.
IMPRESSION:
1. Right great toe paronychia.
2. Folliculitis/abscess, questionable methicillin-resistant Staphylococcus aureus.
3. Lymphadenopathy, right inguinal area.
DISCHARGE INSTRUCTIONS:
1. Wound care instructions, MRSA sheet provided.
2. Prescriptions for Bactrim 3 teaspoons p.o. bid x 14 days, Tylenol with Codeine 1 teaspoon p.o. q. 4 h. p.r.n.
3. Follow up with Pediatrics in 2 days for recheck and for packing removal.
4. Return for fever over 101.5, not controlled with Motrin or Tylenol, signs and symptoms of infection or worse in any way.
DISPOSITION:
The patient was released in good condition.
Sample #3
CHIEF COMPLAINT:
Left great toe ingrown toenail.
HISTORY OF PRESENT ILLNESS:
This is a (XX)-year-old obese female patient who comes in with a complaint of an infected ingrown toenail on the left great toe x3 days. She states that she has cut part of the toenail out but she cannot manage to get the rest out, as it had some pus on the side and swollen and red and tender. There has been no fever, no chills, no numbness or tingling, no decrease in sensation. Nursing notes reviewed.
REVIEW OF SYSTEMS:
The patient denies fever or chills. Review of systems, otherwise, negative.
PAST MEDICAL HISTORY:
History of asthma, hypertension, increased cholesterol, ulcers, diabetes mellitus, depression.
ALLERGIES:
No known drug allergies.
CURRENT MEDICATIONS:
1. Lisinopril.
2. Lexapro.
3. Vytorin.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8, pulse 96, respirations 18, blood pressure 138/86, and pulse ox 99% on room air.
GENERAL: This is a (XX)-year-old obese female patient who is awake and alert, sitting on the gurney, resting comfortably, nontoxic.
EXTREMITIES: On examination of the left great toe, there is edema, erythema and some purulent discharge from the lateral aspect of the nail bed. Range of motion limited secondary to swelling and tenderness. She has a good capillary refill and good pedal pulse.
DIAGNOSTIC TESTS:
None.
PROCEDURES:
I&D and toenail removal. The area was prepped after local anesthesia with bupivacaine without epinephrine. The purulent paronychia was incised and a small amount of purulent discharge was expressed and one third of the nail plate was removed without incident. The wound was then cleaned and dressed. There were no complications.
CONSULTATIONS:
None.
IMPRESSION:
1. Paronychia, left great toe.
2. Ingrown toenail, left great toe.
DISCHARGE INSTRUCTIONS:
1. Wound care instructions were given to the patient.
2. She was given prescriptions for Keflex 500 mg one p.o. q.i.d. x7 days, #28 given, and also for Motrin 800 mg one p.o. q. 8 h. p.r.n., #20 given.
3. Advised to follow up with her family physician in 2 days for recheck and return for worsening signs and symptoms, fever or other concerns.
DISPOSITION:
The patient was released in good condition.
