Cellulitis and abscess of leg except foot Late effect of superficial injury Late effects of accidental fall
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Bee Pollens
 
Attending: ___.
 
Chief Complaint:
RLE erythema
 
Major Surgical or Invasive Procedure:
none

 
History of Present Illness:
___ yr old with no past medical hx presenting with RLE erythema 
and abrasion s/p rollerblading accident with impact on pavement 
two days prior. Onset of erythema from foot, ankle, to distal 
shin yesterday. No change since yesterday. Full range of motion 
and pain only with palpation of abrasion which he cleaned with 
peroxide. Increased drainage from the site, without purulence or 
fluctuance. No fevers, nausea, vomiting or chills. Given 
erythema to ED.
.
In the ED, initial vs were - 98.4, 65, 121/56, 18, 97% RA. On 
exam superficial abrasion to right anterior ankle. Positive 
pulses. Patient was given tetanus booster. Able to Ambulate 
without pain. Pain to palpation along ankle. One gram of 
vancomycin given. Took blood cultures prior. Wound culture was 
sent in ED. Admitted for parenteral antibiotics.
.
ROS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or 
gain. Denies headache, sinus tenderness, rhinorrhea or 
congestion. Denied cough, shortness of breath. Denied chest pain 
or tightness, palpitations. Denied nausea, vomiting, diarrhea, 
constipation or abdominal pain. No recent change in bowel or 
bladder habits. No dysuria. Denied arthralgias or myalgias.
.

 
Past Medical History:
none
 
Social History:
___
Family History:
Patient states no diseases run in family
 
Physical Exam:
VS:120/72, 98.5, 22, 99%RA 74
Gen: NAD
HEENT: OP clear, EOMI
Neck: No JVD, no thyromegaly, no LAD
Cor: RRR no m/r/g
Pulm: CTAB
Abd: +BS, NTND, No HSM
Extrem: RLE with abrasion on ankle, no fluctuance, erythema 
along dorsum of foot extending 4 cm to shin. Marked with pen. 1+ 
edema of ankle. No tenderness to palpation focally. Scab along 
shin. Full range of motion. 2+ pedal pulses. Abrasion on left 
palm, no fluctuance.

 
Pertinent Results:
___ 08:20PM   WBC-12.0* RBC-4.32* HGB-13.5* HCT-36.1* 
MCV-83 MCH-31.2 MCHC-37.4* RDW-12.5
.
___ 08:20PM   PLT COUNT-174
.
___ 08:20PM   GLUCOSE-120* UREA N-15 CREAT-1.0 SODIUM-140 
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-29 ANION GAP-___ellulits: Cellulitis s/p fall. Patient with no past medical 
history therefore no predisposing conditions, no previous 
episodes of MRSA. No evidence of systemic toxicity. No evidence 
of joint involvement. No clear evidence of fracture. Mild 
leukocytosis likely from cellulitis. Improved with overnight IV 
antibiotics.  Patient was sent home with 7 day course of Keflex 
to be completed on ___.

 
Medications on Admission:
none
 
Discharge Medications:
1. Keflex ___ mg Capsule Sig: One (1) Capsule PO four times a 
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Primary:
Right leg cellulitis

 
Discharge Condition:
good, vss, afebrile, on room air

 
Discharge Instructions:
You came to the hospital for redness and swelling around an 
abrasion on your R foot.  You were given antibiotics and there 
does not appear to be any problems with your ankle joint.  
.
Please take the full course of antibiotics.
You may take tylenol for pain.
.
Call your doctor or return to the ED if you have fevers/chills, 
increaseing redness, swelling, purulent discharge from the 
wound, or for nausea, vomitting, diarrhea, or other concerns.
 
Followup Instructions:
___

{'erythema': ['Cellulitis and abscess of leg', 'except foot'], 'abrasion': ['Late effect of superficial injury', 'Late effects of accidental fall']}