A 26-year-old referred for Graves disease. Patient first found to be hyperthyroid shortly after she became pregnant, was placed on PTU 350 mg taken in divided doses until 1 week prior to delivery. She has all the classical symptoms of hyperthyroidism, including tremors, soft frequent stool, being hot, insomnia, weakness in her legs, and exophthalmos.
On physical examination, extraocular movements were fairly full except that she could not converge. Examination of her thyroid revealed the gland to be at least 2 times the normal size with classical, rather mushy, soft feeling of hyperthyroidism. No nodules were noted. Examination of her skin revealed normal amounts of forearm hair but extension of hair on the backs of her hands. She was also beginning to get hair formed on the upper lip at the corners of her mouth. There is no periareolar hair; however, she has a well-developed male escutcheon.
I talked with the patient about this, and when she has been euthyroid for a bit, we will consider measuring her androgen level. Patient was asked to discontinue PTU and obtain a T4 and T3. Appointment was made with Nuclear Medicine for her to have an uptake scan and therapy next week. I decided to investigate the androgen problem at a later date when we will not have the effect of thyroxine on liver metabolism.
FOOTNOTE
Line 7. The article A was inserted before 26 to avoid beginning the sentence with a numeral.
This is a 68-year-old woman who was seen probably about 3 years ago with a large colloid goiter. She was going to have surgery then but declined and came back in more recently because of increasing size of the goiter and the pressure symptoms in her neck and throat. Studies previously done showed this to be a nontoxic goiter. She was essentially euthyroid. Because of its increasing size, the possibility of malignancy had to be considered.
Physical examination was not remarkable except the patient being somewhat overweight and the large goiter which was visible and the right side being larger than the left. The patient, because of religious customs, would not allow a pelvic or rectal examination.
Following surgery, the patient had no problem speaking. She is swallowing and eating solid food. Throat is sore. She did develop a temperature up to 101 and had some rhonchi in both bases on auscultation. Chest x-ray shows discoid atelectasis with probable pneumonitis. Her white count was elevated at a little over 12,000 with a left shift. Temperature this morning is 100 degrees. The wound is clean and dry. The drain has been removed, and one-half of the staples are removed. She will be continued on tetracycline 500 mg q.i.d., and she is instructed to take her Lanoxin daily and her Dyazide as well. We are giving her Synthroid, and she is to take that every day. I have stressed the importance to her son of taking the Synthroid, as she should have no thyroid function. Her calcium was 8.6.
FOOTNOTE
Line 11 (Page 1). The dictator said same for the Final Diagnosis, indicating it is the same as the Admitting Diagnosis. For clarity the Final Diagnosis should be repeated in full.
Line 37 (Page 1). Degrees was not dictated with the temperature of 101 but it is acceptable to add it to be consistent with the later expression.
This 36-year-old man was doing well until 3 years ago, when he developed progressively severe fatigue. At that time he had been in a stressful job situation. However, these symptoms have persisted and gotten worse, although the stress has improved. There is no relation to meals or time of day, although he is somewhat more tired in the afternoons. He sleeps 7 to 8 hours during the week and 12 hours on weekends. Chemistry-2, CBC, Epstein-Barr studies, and thyroid function tests have been normal. Was tried on Thyrolar one-half grain because of low normal T4, but there was no benefit. Has received Parnate, Nardil, and other antidepressants, including vitamin B12 injections, without any benefit. He has a 3-year history of constant burning in the eyes. An ophthalmologist did not find anything wrong.
REVIEW OF SYSTEMS
Has periodic dizziness particularly when standing up rapidly, occasional tinnitus, frequent constipation and occasional diarrhea, nocturia x2 or 3, cold extremities, and dry skin of relatively recent onset. Has some anxiety and insomnia and is depressed, apparently in relation to his condition.
FAMILY HISTORY
Father has heart disease. Brother has retinitis pigmentosa.
GROSS NEUROLOGIC: Gross neurologic examination is normal.
SKIN: Skin is normal.
RECTAL: Rectal examination not done.
ASSESSMENT
1. Chronic fatigue.
2. Burning eyes.
3. Depression.
4. Signs of possible hypothyroidism.
5. Constipation and diarrhea.
PLAN
We will check basal temperatures and begin thyroid prescription if low. Gave therapeutic trial of 6-cc vitamin C, 4-cc calcium/magnesium, 1 cc of B6, B12, B5, and B complex IV. Will repeat if helpful. Other recommendations as noted and return in 4 weeks.
FOOTNOTE
Line 13 (Page 1). Chem was expanded to Chemistry. Exam was expanded to Examination.
Line 35 (Page 1). Exam was expanded to Physical Examination. Line 36 (Page 1). Height and weight was added for clarity.
Lines 36-47 (Page 1). The subheadings were added in Physical Examination to follow proper format.
Line 9 (Page 2). Alternative: I.V. (intravenous). The slang term cal/mag was expanded to calcium/magnesium for clarity.
Dysphagia with odynophagia. Suspect cervical muscle spasm in lingual and supraglottic region. Questionable relationship to stress etiology.
PLAN
Patient was educated in clinical findings, and at this point in time, I am unable to establish any specific pathology and would concur that evaluation at a major medical center may be helpful.
An 11-7/12-year-old female who states that she has heard a noise in her right ear off and on for the past few weeks. She has had no fever, no rhinorrhea, no cough, no vomiting, no diarrhea, no dizziness, no headache. She has suffered no loss of consciousness. She takes no medications at the present time.
PAST MEDICAL HISTORY
No hospitalizations. No operations. No allergies. Immunizations are current.
PHYSICAL EXAMINATION
GENERAL: Alert, well-nourished, well-developed female in no acute distress.
SKIN: Clear.
HEENT: Eyes: Sclerae white. Conjunctivae clear. Fundi within normal limits. Ears, nose, throat entirely within normal limits.
NECK: Supple. No adenopathy.
LUNGS: Clear.
HEART: Regular rate and rhythm without murmurs.
ABDOMEN: Soft, nontender. No masses or hepatosplenomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
GENITALIA: Normal Tanner stage 2 female external genitalia.
NEUROLOGIC: Tone within normal limits. Deep tendon reflexes 2+. Finger-to-nose intact without tremor. Audiometry is within normal limits.
IMPRESSION
Questionable tinnitus — etiology unclear.
PLAN
1. Symptomatic care.
2. Return to clinic if tinnitus does not resolve.
3. Hemoglobin.
4. Urinalysis.
5. TB tine.
FOOTNOTE
Lines 18-31. The subheadings were added for clarity.
This 9-year-old black girl was well until yesterday morning, when she awakened with fever and sore throat. Mother states her temperature was 99.6 orally at noon yesterday, 100.6 at about 8 p.m., and 101.2 this morning. Temperature comes down with Tylenol but then shoots up again. Sore throat has become increasingly severe, and today the child will not swallow anything. She also complains of pain in the right ear on swallowing. She is not coughing and has had no rhinitis or GI symptoms. Past medical history is negative. She has no known allergies. Some of the other kids at school have been out with strep.
OBJECTIVE
Examination shows a normally developed, chubby child in moderately severe distress. She is crying. Oral temperature is 102.4, pulse 108, respirations 28. The skin is hot and moist. There is no rash. The pharynx is diffusely edematous and deeply injected, and a small amount of exudate is noted over the tonsils. No ulcers are noted, and the oral mucosa is normal. There are large, tender nodes in the jugulodigastric areas bilaterally, and a few small nontender posterior cervical nodes are palpable as well. The ear canals are clear. The tympanic membranes are flat and gray. Hearing is grossly normal bilaterally. Heart is regular without murmurs or clicks. Lungs are clear to auscultation. The abdomen is soft and nontender, without masses or organomegaly. A streptococcal screen in the office is positive.
ASSESSMENT
Acute streptococcal pharyngitis.
PLAN
1. Penicillin V potassium 250 mg per teaspoonful to be taken in a dose of 1 teaspoonful q.i.d. x10 days.
2. Tylenol up to 1 g q.4h. for pain and fever.
3. Encourage oral fluids, soup, pop, Popsicles.
4. Hot saline gargles p.r.n. for throat pain.
5. Mother is to call in, in 24 hours, to report progress.
6. Mother is reminded not to give ASA.
FOOTNOTE
Lines 3-22. Alternative: Transcribe in SOAP format.
This 21-year-old lady stated that she has been having some problems with a “swollen gland on the right side”. She had seen you about a week and a half ago, and you had ruled out the presence of a stone within the salivary gland. She states the swelling “tends to go up and down”.
Her general health is described as good, but she does have asthma. She is presently taking Motrin, Marax, and an inhaler.
Physical examination reveals ear canals are clear. Tympanic membranes normal. Nasal airway adequate, no discharge. Throat reveals normal mucous membrane. No postnasal drainage. Her right submandibular gland is slightly enlarged but soft and nontender.
Under the operating microscope, I was able to dilate Wharton duct on the right, and after dilatation the gland resumed its normal size. There was no evidence of purulent discharge or calculi. Hopefully, this will do the trick.
I explained to her that we can only treat this either symptomatically or excise the gland, and I suggested that symptomatic treatment for a while is indicated.
Thank you for the referral. If I can be of any further assistance, please let me know.
Best regards,
Name.
FOOTNOTE
Line 13. Re was not dictated but was added to demonstrate proper letter format.
Ear canals are clear. Tympanic membranes are normal. Nasal airway is adequate. Septum slightly deviated to the right. No discharge. Throat reveals normal mucous membrane. No evidence of inflammation. No PND (postnasal drainage). She does have a couple of little lymphoid plaques, both in the pharynx and in the area where tonsils were removed. These are not neoplasms and not presently inflamed, just a tiny bit juicy. Neck reveals no adenopathy. Thyroid and trachea are normal.
IMPRESSION
Very mild lymphoid hyperplasia of the tonsillar fossae postoperative and the nasopharynx.
DISPOSITION
Reassured, explained what is going on, and she is to return p.r.n. Encouraged her not to take antibiotics for just every sore throat.
FOOTNOTE
Line 7. Exam was expanded to Examination in the report.
Line 11. The abbreviation PND was expanded to postnasal drainage in this report.
Line 18. Fossas was changed to fossae, plural of fossa.
This 17-year-old woman was seen in consultation with her mother regarding problems referable to her nose. The patient has had progressive problems of congestion and sniffing with difficulty moving air through her nose and sensation of pressure. She is a “mouth breather,” and has a history of allergy to pollens and dust. Patient feels these problems are becoming more severe. Her complaints are fairly consistent.
EXAMINATION
She presents with edema of her nasal mucosa, increase in the size of the turbinates, deviation of the nasal septum, and a rather narrowed nasal airway.
DIAGNOSES
1. Probable allergic rhinitis with hypertrophy of the turbinates.
2. Deviated nasal septum.
3. Narrow inadequate nasal airway.
COMMENTS
1. I have discussed with this patient and with her mother the surgical approach to improving her nasal airway with septoplasty, possible submucous resection of deviated portions of the septum, and possible reduction of the inferior turbinates. At the same time I would be performing a rhinoplasty procedure to smooth out the dorsal nose as well.
2. Because of the history of allergies to pollens, dust, and environmental pollutants, it is quite possible patient will continue to have some sniffing, and consequently the degree of improvement of her nasal airway with surgery cannot be precisely determined.
FOOTNOTE
Line 7. This was added to avoid beginning the sentence with a numeral.
Has continued to have episodes of coughing and wheezing over the course of the past several years along with persistence of some rhinitis. His hearing is apparently fine, although he has had some serous otitis media again as well.
We decided to skin-test him again, and there is a marked change in his skin tests. He now shows reactions to tree, grass, and weed pollens, house dust, cat dander, multiple genera of mold spores, animal feathers, and house dust mites. The dog was removed from the house with no change in the patient’s symptoms; indeed, there was some progression of his symptoms. I therefore have decided that a course of immunotherapy would be appropriate, and he is going to start that. Since his brother is coming to my office for administration of his injections, will be getting his injections in my office as well at his mother’s request.
FOOTNOTE
Line 16. His was changed to the patient’s for clarity.
He was brought to the emergency room with a right epistaxis with clots in the nose. Patient is on Coumadin.
EXAMINATION
The clots were removed from the right nostril, and an active venous bleeder on the right anterior septum was identified. This was cauterized with silver nitrate and an anterior pack placed. The left side appeared to have no active bleeding. He was observed for a few minutes, and no further bleeding of an active nature was identified. Some tape as a counter pressure was applied to the nose and the throat checked also. There is just an old clot posterior that is sticking down just enough so that you can see it but cannot reach it with an instrument. This was left in place.
I recommend that we leave the pack in until Wednesday morning if patient tolerates it. He is apparently already on antibiotics, pain medicines, and oxygen, so no additional orders are indicated at this time.
Patient is seen for nasal blockage. Found to have nasal polyps, swollen turbinates, and also chronic sinusitis on the right. He improved somewhat on medicine, but still had the basic problems, so finally scheduled for right Caldwell-Luc, cautery of the turbinates, and polypectomy.
Examination of right postauricular mastoid wound site demonstrates less erythema with mild induration, and packing demonstrates thick, cloudy secretions with no malodor. There appear to be no frank pus pockets evident, and debridement was performed with application of Betadine ointment. Betadine-impregnated iodoform gauze was additionally placed with approximately 1-1/2 inches and patient’s wife instructed in wound care.
ASSESSMENT
Right postauricular mastoid wound infection with fat or hematoma liquefaction.
FOOTNOTE
Lines 9-10. Appears was changed to appear for proper subject-verb agreement. (There appear to be no ... pockets ...)
At the request of my patient, I am forwarding this brief medical report.
History
The patient, a 24-year-old woman, was seen in consultation regarding problems referable to her nasal breathing. The patient complains of progressive congestion, a pressure sensation within the nose, sniffing, and stuffiness. In addition, she has had episodes of sneezing, itching, and watery eyes. She has more problems breathing through the right side of the nose than the left.
Examination
Examination reveals the nasal septum to have somewhat of an S-shaped configuration with the midsection curved to the right of the midline and the caudal edge of the quadrilateral cartilage to the left of the midline. There is marked obstruction of the right nasal passage. She has some asymmetry to the dorsal nose as well.
Diagnoses
1. Inadequate nasal airway.
2. Deviated nasal septum.
3. Possible rhinitis.
Comments
1. I have discussed with the patient the treatment of this condition with a nasal septoplasty with partial submucous resection.
2. In addition, simultaneously a modified rhinoplasty would be performed.
3. The patient would appreciate a letter from Blue Cross stating that these treatments would be covered on her group health insurance program.
4. The surgery would be performed in an office setting and would not require any hospitalization.
Sincerely,
Name.
FOOTNOTE
Line 13 (Page 1). Re was not dictated but was added to demonstrate proper letter format.
Lines 37-40 (Page 1). The physician dictated the numeral 1 but failed to enumerate the remaining diagnoses, dictating commas to separate the diagnoses. Add the remaining numerals.
Michelle was first seen by me in February. At that time she was complaining of vague symptoms. She was under stress, but this was related to her work. She also had a history of a kidney stone.
On examination at that time, she had red scaly patches under her ears, which subsequently turned out to be an allergy to her hair spray. She had a left cervical posterior triangle node which was mobile and nontender, a scar over her right scapula where she had had a hemangioma at age 6 weeks, and bilateral mammary implants.
All the blood tests that were obtained were negative except for a low ferritin, related to her menstruating and her 2 pregnancies. She was put on iron supplements. She had a chest x-ray that was entirely normal.
She was seen again about a month later. Her cervical node and axillary node had disappeared by then. Because her nodes disappeared, she did not see a head and neck surgeon, and on examination today she certainly does not have these nodes. A copy of her lab data is enclosed, and this was all essentially normal aside from the low ferritin.
In 1986, her blood pressure was 92/56 and she weighed 109-1/4 pounds. Today her blood pressure is 106/60 and she weighs 111 pounds. There has been no change in her blood pressure or her weight.
On examination today she still has the scar over her right shoulder blade. I cannot today feel any axillary or cervical node enlargement whatever. She still has the bilateral breast implants and a low C-section scar. She tells me that she had a recent pelvic, Pap smear, and rectal examination by her gynecologist, and this was not done. At the moment she is asymptomatic. Indeed, she is only seeing me now because she is apparently having some trouble in getting medical insurance - this despite the fact that she has not seen a physician for any problems since last seeing me for a routine checkup.
I have ordered no routine or other blood studies at the time of this dictation. She has had a recent Pap smear, is asymptomatic, is taking iron, and blood tests were essentially negative. She has continued to feel good, not required medical care, and informs me that she has been in good health and seen no other physician during this time.
Sincerely yours,
Name.
FOOTNOTE
Line 9 (Page 1). Re was not dictated but was added to demonstrate proper letter format.
Line 44 (Page 1). Alternative: Cesarean section.
Line 48 (Page 1). The dictated period was changed to a dash. A comma would also be acceptable.
The patient returned for reevaluation because of complaints of dizziness which are probably lightheadedness. She has been seen here previously twice because of the same complaints. She did give a history of having been seen by a neurologist for frontal-type headache discomfort. She apparently was complaining also of tinnitus. The neurologist who evaluated her symptoms ordered a CAT scan of her sinuses, which did show mucosal thickening and a suggestion of an air-fluid level. At any rate she apparently went to the clinic, and I do not have a record of that visit at all. When I saw her, she was complaining of lightheadedness and allergic-type nasal symptoms with obstruction.
A brief ENT examination was performed. There was some bogginess of the nasal mucosa. There was slight cerumen impaction, which was removed with a pick. Weber and Rinne tests were negative. I started her on Beconase and Nasalide spray and asked her to return in a month.
The patient comes in stating he has some irritation in his right ear. He does wear an ITE (in-the-ear) aid on that side. He also has what he terms a smell hallucination in that there is kind of a musty smell in his nose when he inhales and exhales. He has been using some Ocean spray from time to time.
PHYSICAL EXAMINATION
Examination of the ears reveal that in the right ear, external canal is slightly irritated at the outer third, but the inner two-thirds is okay. Tympanic membrane is intact and not inflamed. Left ear is clear. There is no cerumen in either side. Examination of the nose reveals the airway is quite adequate. Septum slightly deviated to the right. No evidence of polyps or abnormal discharge. Throat reveals normal mucous membrane. No evidence of inflammation. Neck reveals no adenopathy.
IMPRESSION
Mild right external otitis.
DISPOSITION
Recommended 0.5% hydrocortisone cream in the outer ear and a couple drops of alcohol at night before he goes to bed. Try to keep the canal dry. Nasal irrigation using a normal saline solution, and he was asked to return if symptoms progress and we will go ahead and get a sinus view.
CHART NOTE
Examination of his right ear reveals some inflammation of the tympanic membrane, a little moisture in the canal. I am sure he has a serous otitis back there, but rather than put a tube in at the present time, give him some Ceclor 250 mg, #30, and ask him to return in 2 weeks for tube insertion.
CHART NOTE
PHYSICAL EXAMINATION
Right ear canal is small and swollen, difficult to work with, and required the operating microscope. By use of both suction and hydrogen peroxide irrigation, a rather large bolus of fungus was removed from the tympanic membrane. Tympanic membrane appeared intact.
Spectazole was then applied after drying the canal, and she was asked to return for followup.
IMPRESSION
External otitis.
DISPOSITION
Spectazole and followup.
FOOTNOTE
Line 8 (Page 1). ITE was translated for clarity.
Line 11 (Page 1). Ocean is a trade name for a nasal spray.
Line 13 (Page 1). Exam was expanded to Examination in the report.
Line 28 (Page 1). The dictated one-half percent is represented correctly as 0.5% for metric measurement consistency.
First seen in my office on referral. Enclosed is a copy of his referral notice.
Examination on the 19th did reveal bilateral serous otitis, decreased nasal airway secondary to adenoid hypertrophy, and bilateral tonsillar hypertrophy.
It is my recommendation that he undergo an adenotonsillectomy with the insertion of ventilating tubes.
The patient was seen for ear problems. Has been followed for ventilation tube placement twice in the past. The tubes were out and has had very dull, amber tympanic membranes with an abnormal impedance bilaterally. Diagnosis of severe otitis media. Scheduled for placement of ventilation tubes. Mother has been informed of possible complications including, but not limited to, death.
4. Urinary frequency. Rule out urinary tract infection.
5. Hypertrophy of gums.
6. Right popliteal mass.
7. Possible psoriasis.
DISCHARGEDIAGNOSES
1. Left lower leg cellulitis.
2. Left lower leg ulceration.
3. Diabetes mellitus.
4. Urinary frequency. Rule out urinary tract infection.
5. Hypertrophy of gums.
6. Right popliteal mass.
7. Possible psoriasis.
ADMIT INFORMATION
Full history and physical have been dictated. Briefly, this is a 48-year-old white female with obesity and diabetes who has had a smoldering left lower extremity cellulitis for the past 2 to 3 months. It is possibly related to her pruritus and psoriasis. She has been treated in the past with Coumadin and IV antibiotics. On the day of admission she presented to my office with worsening of the cellulitis and a new 2-cm ulceration and was admitted for IV antibiotics and further evaluation.
ALLERGIES
ALLERGY TO PENICILLIN AND SULFA AND POSSIBLY TO COUMADIN.
Medications on admission were Procardia, Mellaril, Aldactone, Glucotrol, and hydrochlorothiazide. The extremities revealed bilateral edema 1 to 2+ to the knees, with erythema and diffuse excoriations with erythema from the ankle to the midshin area on the left lower extremity. She had a 2 x 2-cm superficial ulcer on the lateral aspect of the ankle. Of note on the right popliteal fossa, she had a mobile, firm mass, 2 x 2 cm.
Laboratory on admission revealed urine with 80 to 150 wbc’s, 3 to 6 rbc’s, 10 to 15 epithelials, but only a few bacteria. Sodium was 138. Electrolytes were normal. BUN and creatinine were normal. The creatinine was 1.4, which is probably acceptable for this obese woman. PT was slightly elevated at 15.6. PTT was normal. Subsequent chemistry panel was essentially normal. CBC revealed a white blood cell count of 6, hemoglobin of 12, hematocrit of 35, with 345,000 platelets and a normal smear.
HOSPITAL COURSE BY PROBLEMS
1. Cellulitis and ulceration as well as chronic skin problems. The patient was seen in consultation by a dermatologist who confirmed my diagnosis of cellulitis. She was placed on IV Kefzol for 48 hours with marked improvement in her cellulitis. Her skin condition was consistent with lichen simplex chronicus, and she was begun on Topicort cream b.i.d. Her Coumadin was not continued as she had no venogram or Doppler evidence of deep venous thrombosis in the past. As well, she seems to feel that the Coumadin made her rash worse.
2. Gum hypertrophy. I felt that this was most likely periodontal disease but checked a CBC to make sure she had no evidence of leukemia with leukemic infiltrates. The CBC was normal, and she will see her private dentist on discharge.
3. History of urinary tract infection. The admission UA was abnormal. I have obtained a catheterized specimen for urinary culture. As she will be on Keflex antibiotics for the cellulitis on discharge, I will give no other antibiotics until the results of the urine culture are back.
DISCHARGE MEDICATIONS
Glyburide 2.5 mg q.d., Keflex 500 mg p.o. q.i.d., Lasix 20 mg q.d., Mellaril 50 mg q.h.s., Topicort cream to affected areas b.i.d., and normal saline dressing changes for wound care.
FOOTNOTE
Line 16 (Page 1). Although the dictator said “as above” for the Discharge Diagnoses, it is preferable to type the diagnosis in full.
Lines 28, 29 (Page 1). Alternative: 2-3 months.
Line 26 (Page 1). Allergies were classified under a separate heading for clarity.
Lines 46, 47 (Page 1). Alternative: 80-150 wbc’s, 3-6 rbc’s, 10-15 epithelials. The slang term epis was translated as epithelials. Alternative: epithelial cells.
Line 1 (Page 2). Chem panel was expanded to chemistry panel.
Line 8 (Page 2). Alternative: I.V.
Line 22 (Page 2). The slang term cath was translated as catheterized.
The patient is an elderly, pleasant female who is quite cooperative.She was admitted to the hospital because of cellulitis of the right lower extremity.There has been blistering of the area on the dorsum of the foot as well as higher up towards the ankle.She has redness extending all the way up to the mid-pretibial area.There is no history of lymphadenopathy, and judging from the chart, she has been afebrile.She was started, after finding out that her white count was abnormal, on Cefobid and tobramycin and infectious disease consultation sought.
PHYSICAL EXAMINATION
Exam today shows a temperature of 37 degrees Centigrade, a blood pressure of 130/70, a respiratory rate of 20, and pulse rate of 80. General appearance:An elderly female in no acute distress.
Head and ENT:Grossly negative. Neck:Supple. Lungs:Clear and resonant. Heart:Grade 1 systolic murmur; otherwise negative.
Abdomen:Scars of surgery.The abdomen is not obese but protruding.She has some left lower quadrant discomfort that is mild. Vaginal and rectal:Not done. Lymph nodes:No enlargement. Exam of the extremities reveals blistering cellulitis over the dorsum of the foot with swelling and extension of the abnormal coloration to the mid-pretibial area.The foot appears warmer than the other.
After sterile preparation the 2 blisters were aspirated, 0.2 cc of fluid was taken out, and this was sent for Gram stain and culture.
IMPRESSION
Probable streptococcus cellulitis.
DISCUSSION
The patient has had a Gram stain done yesterday, and it does show gram-positive cocci.This may well be staph, but I think we should give her penicillin till the culture reports are out.The blistering is typical of strep.I would go ahead and give her 2 million q.6h. of the penicillin and modify therapy according to culture report.
I thank you for allowing me to participate in the care of this pleasant, elderly female and will reassess p.r.n.
FOOTNOTE
Line 42.The brief form strep was expanded to streptococcus in the Impression.
