Cellulitis of right lower limb Unspecified streptococcus as the cause of diseases classified elsewhere Hypothyroidism unspecified Dermatitis unspecified
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
leg pain, rash
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
PCP:
Name: ___ 
Location: ___ 
GROUP 
Address: ___, ___ 
Phone: ___ 
Fax: ___ 

___ yo M with eczema well controlled, hypothyroidism, who 
presents with acute LLE rash, pain, and fever.  The patient 
first noticed the onset of redness in inner thigh with the 
feeling of a muscle pull.  Over the next day he noticed a rash 
in his LLE at the shin, punctate, which then became more 
confluent.  This was assoc with a sharper pain.  He describes HA 
and feeling hazy as well. He also reports fever to 102.  He 
denies recent trauma to leg or bug bite.  He denies recent 
travel.  He otherwise has felt well and denies vision change, 
CP, SOB, cough, n/v/d, bloody stool, dysuria, or leg swelling,=.

He saw his PCP and was referred to dermatology.  The lower rash 
was biopsied but derm was concerned about cellulitis.  He was 
therefore referred into the hospital for more aggressive 
treatment.  He currently feels better and notes that his rash 
has stopped spreading.

10 point review of systems reviewed otherwise negative except as 
listed above
 
Past Medical History:
ECZEMA                                                          
___'S THYROIDITIS                                         
ORTHOSTATIC HYPOTENSION                                         
ADRENAL FATIGUE                                                 
BENIGN PROSTATIC HYPERTROPHY 
 
Social History:
___
Family History:
Father with prostate cancer.  mother with COPD and renal failure
 
Physical Exam:
VS: T96.8, BP 151/101, HR 98, RR 14, 100%RA
GEN: well appearing in NAD
HEENT: MMM OP clear anicteric sclera
NECK: supple no LAD
HEART: RRR no mrf
LUNG: CTAB
ABD: soft NT/ND +BS no rebound or guarding
EXT: Mild blanching erythema in inner thigh of RLE, mildly 
tender.  No tender LAD or fluctuance or drainage.  Distal ___ at 
shin with non-blanching confluent erythema, tender to touch, no 
discharge.  Connecting the two is a mild erythematous cord.  
Mild eczematous change in RLE
SKIN: as above
NEURO: no focal deficits
 
Pertinent Results:
___ 04:30AM URINE  COLOR-Straw APPEAR-Clear SP ___
___ 04:30AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG 
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 
LEUK-NEG
___ 02:44AM   ___ PTT-31.6 ___
___ 12:42AM   LACTATE-2.4*
___ 12:30AM   GLUCOSE-96 UREA N-21* CREAT-0.9 SODIUM-137 
POTASSIUM-3.6 CHLORIDE-95* TOTAL CO2-28 ANION GAP-18
___ 12:30AM   WBC-5.9 RBC-4.71 HGB-14.8 HCT-43.2 MCV-92 
MCH-31.4 MCHC-34.3 RDW-12.6 RDWSD-42.3
___ 12:30AM   NEUTS-54.1 ___ MONOS-16.0* EOS-0.0* 
BASOS-0.5 IM ___ AbsNeut-3.20 AbsLymp-1.72 AbsMono-0.95* 
AbsEos-0.00* AbsBaso-0.03
___ 12:30AM   PLT COUNT-___ with hypothyroidism presents with acute RLE erythema c/w 
acute cellulitis with lymphangitis.

Acute RLE cellulitis: 
Exam most consistent with acute cellulitis of distal RLE with 
lymphatic spread to upper RLE.  There is no tender LAD or 
fluctuance to suggest abscess.  There is no discharge.  portal 
of entry likely eczema on leg.  Vasculitis is also to be 
considered though less likely.  There is no characteristic 
feature of Lyme disease.  Strep is the most likely cause.  He 
was started on IV with stabilization and improvement in his 
overall condition.  The derm biopsy results were reviewed.  
Dermatology here was consulted for a second opinion and agreed 
that this was likely related to cellulitis, strep.  After 48 hrs 
of IV Vanco, he was transitioned to Dicloxacillin to complete a 
10 day course.  His Doxycycline was stopped on discharge.  Lyme 
negative.  Blood cultures pending on discharge.

Hypothyroidism: Continued home pork thyroid

 
Medications on Admission:
Pork Thyroid ___ daily
 
Medications - OTC
ASCORBATE CALCIUM-BIOFLAVONOID [___] - Dosage uncertain - 
(Prescribed by Other Provider; ___)
BETA CISTEROL - Dosage uncertain -  (Prescribed by Other
Provider; ___)
CALCIUM CITRATE - Dosage uncertain -  (Prescribed by Other
Provider; ___)
COENZYME Q10 - Dosage uncertain -  (Prescribed by Other 
Provider;
___)
GARLIC - Dosage uncertain -  (Prescribed by Other Provider; ___)
GRAPE SEED EXTRACT - Dosage uncertain -  (Prescribed by Other
Provider; ___)
GUGGALIPID - Dosage uncertain -  (OTC)
MAGNESIUM CITRATE - Dosage uncertain -  (Prescribed by Other
Provider; ___)
MULTIVITAMIN - multivitamin tablet. 1 Tablet(s) by mouth once a
day -  (OTC)
OMEGA-3 FATTY ACIDS [FISH OIL CONCENTRATE] - Dosage uncertain - 
(Prescribed by Other Provider)
PANTETHINE - Dosage uncertain -  (OTC)
PSYLLIUM HUSK [FIBER (PSYLLIUM HUSK)] - Dosage uncertain - 
(Prescribed by Other Provider; ___)
PYCNOGENAL - Dosage uncertain -  (___)
SAW ___ - Dosage uncertain -  (OTC)
VITAMIN A-VITAMIN C-VIT E-MIN [ANTIOXIDANT FORMULA] - Dosage
uncertain -  (Prescribed by Other Provider)
VITAMIN B COMPLEX [B-50 COMPLEX] - Dosage uncertain - 
(Prescribed by Other Provider; ___)
VITAMIN E - Dosage uncertain -  (Prescribed by Other Provider;
___)

 
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain fever 
2. thyroid (pork) 162.5 mg oral DAILY 
3. DiCLOXacillin 500 mg PO Q6H 
RX *dicloxacillin 500 mg 1 capsule(s) by mouth four times a day 
Disp #*32 Capsule Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Acute RLE cellulitis
Hypothyroidism

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
You were admitted for evaluation of right leg rash, likely 
caused by infection in your skin (cellulitis).  Please complete 
your doxycycline given to you previously (subtract the last 2 
days worth), and complete the course of Dicloxicillin given to 
you.  please follow up with your PCP in the next ___ days.

You can use Vaseline to your wound with dry gauze dressing 
change daily
 
Followup Instructions:
___

{'leg pain': ['Cellulitis of right lower limb', 'Hypothyroidism'], 'rash': ['Cellulitis of right lower limb', 'Dermatitis'], 'fever': ['Cellulitis of right lower limb'], 'HA': ['Cellulitis of right lower limb'], 'hazy': ['Cellulitis of right lower limb'], 'redness': ['Cellulitis of right lower limb'], 'muscle pull': ['Cellulitis of right lower limb'], 'punctate rash': ['Cellulitis of right lower limb'], 'confluent rash': ['Cellulitis of right lower limb'], 'sharper pain': ['Cellulitis of right lower limb'], 'eczema': ['Dermatitis'], 'hypothyroidism': ['Hypothyroidism']}