Cellulitis and abscess of leg except foot Obesity unspecified Esophageal reflux Unspecified acquired hypothyroidism
 
Name:  ___             Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Ortho-Cyclen (21) / Compazine / Honey
 
Attending: ___.
 
Chief Complaint:
L thigh infection 
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
___ F presents to the BID ___ after being seen at ___ 
twice in 3 days for left thigh pain and erythema. She first 
noticed erythema on ___. On ___, she noted an expanding 
"ball" of fluctance. She took her kids to the ___, but while 
there started to feel ill; she took her temp which was 101 and 
presented to the ___ at ___. At ___, drainage was attempted 
by needle aspiration, but no fluid was obtained. She got a dose 
of CTX in the ___ on ___. She returned to the ___ 
___ ___ became the area of erythema had expanded. She got 
another dose of CTX and was sent home with po Keflex. Given 
worsening redness and expanding "ball" of fluctuance, the pt's 
brother-in-law is (former surgeon at ___ encouraged her to 
come in for further evaluation.  
.  
In the ___, initial vitals: 99.4 109 ___ 99% RA. Exam was 
notable for an area of eryhtema which has progressed but 1.5" 
circumfirentially from the area that was demarkated at ___. 
There was large area of fluctuance, and US of the areashowed a 
fluid collection. This area was incised and drained (50-75 cc of 
pus) and then packed. A fluid sample was sent for gram stain and 
Cx. She recieved morphine for pain, 1g vanc, and 1L NS. Given 
that the patient has been having fevers and the area of 
cellulitis was expanding on CTX, she is being admitted for IV 
abx and close observation. Vitals prior to transfer: T 99.3, 
114/81, 83, 18, 100% RA.  

 
Past Medical History:
Obestiy  
hypothyroidism  
GERD  
Gave birth to her daughter ___-section  

 
Social History:
___
Family History:
NC
 
Physical Exam:
VS: T 98.8, BP 103/64, HR 91, RR 22, 98% RA  
GENERAL: Well-appearing obese F in NAD, comfortable, 
appropriate.  
HEENT: NC/AT, sclerae anicteric, MMM, OP clear.  
HEART: RRR, no MRG, nl S1-S2.  
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored. 
 
ABDOMEN: Soft/NT/ND  
EXTREMITIES: WWP, no c/c/e  
SKIN: Areas off cellulitis demarkated on the right inner thigh 
near the groin from ___ yesterday as well as a line for our ___ 
today. Line from today is 1.5-2" away from ___ line. Area of 
erythema has somewhat regressed from the line demarkated today. 
Area of I&D gressed with gauze.  
NEURO: Awake, alert, talkative, CNs II-XII grossly intact.  

 
Pertinent Results:
___ 06:55PM BLOOD WBC-11.7* RBC-4.19* Hgb-12.9 Hct-37.6 
MCV-90 MCH-30.8 MCHC-34.4 RDW-12.4 Plt ___
___ 06:55PM BLOOD Neuts-71.1* ___ Monos-4.1 Eos-0.6 
Baso-0.5
___ 03:10PM BLOOD WBC-7.6 RBC-3.79* Hgb-11.6* Hct-33.8* 
MCV-89 MCH-30.7 MCHC-34.5 RDW-11.8 Plt ___
___ 06:55PM BLOOD Glucose-100 UreaN-12 Creat-0.8 Na-140 
K-4.1 Cl-101 HCO3-29 AnGap-14
___ 07:04PM BLOOD Lactate-1.2

micro: 
blood cx pending
wound cx 
   GRAM STAIN (Final ___: 
      2+   ___ per 1000X FIELD):   POLYMORPHONUCLEAR 
LEUKOCYTES. 
      NO MICROORGANISMS SEEN. 

   WOUND CULTURE (Final ___: 
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    RARE GROWTH. 

   ANAEROBIC CULTURE (Preliminary):    RESULTS PENDING. 

 
Brief Hospital Course:
___ F who presents with expanding area of cellulitis of the 
left thigh and underlying abscess, s/p I&D in the ___.  
.  
# cellulitis/abscess: Patient presented to ___ with worsening 
pain and swelling of her left thigh. Also noted expanding "ball" 
of fluctuance.  Patient had previously gone to ___ twice 
and was treated with ceftriaxone. She was discharged from the ___ 
on Keflex after her second visit. Attempt at drainage was 
unsuccessful and no wound cultures were obtained. On 
presentation to BI ___ she was afebrile (Tmax 99.4) and found to 
have area of erythema which progressed 1.5 inches from area 
marked at ___ the day prior. There was fluctuance and US 
showed fluid collection. The area was incised and drained (50-75 
cc of pus) and then packed. Gram stain showed 2+ PMNs and no 
organisms. Wound cultures were sent and eventually grew out rare 
coagulase negative staph (however had already received 
ceftriaxone and Keflex at OSH). She was started on vancomycin.  
Pain was treated with morphine. On the floor patient looked 
well. She was continued on vancomycin and started on 
amoxicillin. She remained afebrile and repeat WBC count in the 
afternoon improved. Her pain was controlled without narcotics. 
Patient was discharged with plans to complete course of Bactrim 
and Keflex with frequent ___ visits for wound care.  
.  
# Hypothyroidism: Con't home levothyroxine  
.  
# GERD: Nexium not on formulary, so given omeprazole while 
admitted. 
.
transitional issues
- patient will need frequent wound care for dressing changes
- wound cultures were pending at time of discharge
- patient was full code on this admission

 
Medications on Admission:
Nexium  
levothyroxine 112mcg  

 
Discharge Medications:
1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY 
(Daily).  
2. Bactrim DS 800-160 mg Tablet Sig: One (1) Tablet PO twice a 
day for 9 days.
Disp:*18 Tablet(s)* Refills:*0*
3. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.) 
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.  
4. Keflex ___ mg Capsule Sig: One (1) Capsule PO four times a 
day for 9 days.
Disp:*36 Capsule(s)* Refills:*0*
5. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
every eight (8) hours as needed for pain for 3 days: Do not 
drive or drink alcohol while taking this medication.
Disp:*10 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
___ Diagnosis:
Primary diagnosis: cellulitis, abscess

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

 
Discharge Instructions:
Dear Ms. ___,

It was a pleasure caring for you while you were in the hospital. 
 You were admitted because you were found to have an abscess and 
a skin infection of your left inner thigh.  You had the abscess 
drained in the emergency department and were started on 
intravenous antibiotics.  You felt well overnight without fevers 
and the redness of your skin started to improve.  Your white 
blood cell count normalized.  We do not have the culture results 
back from the wound, but these should be follwed up by your 
primary doctor.  
.
Please continue to take all medications as prescribed and follow 
up with your doctors as ___. 
.
Please START taking:
--Keflex (please take until ___
--Bactrim (please take until ___
--Percocet (do not drive or drink alcohol while taking this 
medication).
 
Followup Instructions:
___

{'erythema': ['Cellulitis and abscess of leg, except foot'], 'pain': ['Cellulitis and abscess of leg, except foot'], 'fever': ['Cellulitis and abscess of leg, except foot'], 'fluctuance': ['Cellulitis and abscess of leg, except foot'], 'swelling': ['Cellulitis and abscess of leg, except foot'], 'obesity': ['Obesity'], 'hypothyroidism': ['Unspecified acquired hypothyroidism'], 'GERD': ['Esophageal reflux']}