HISTORY AND PHYSICAL EXAMINATION
HISTORY
This 17-year-old was admitted via the emergency room. She gives a history of shooting crank. Since that time, the left antecubital space has been infected.
PAST HISTORY
Patient has been shooting for at least a year.
She denies use of drugs other than crank.
The patient has a 2-year-old and a 3-week-old child, has been in the hospital only for that. Denies accidents, injuries, or other infections.
SOCIAL HISTORY
Patient is a 17-year-old IV drug user.
PHYSICAL EXAMINATION
VITAL SIGNS: Temperature 102.2 degrees. Pulse 112. Respirations 20. Blood pressure 104/60.
GENERAL: Well-developed, well-nourished, English-speaking, Caucasian 17-year-old.
EENT: No gross abnormalities. Pupils constricted. Fair dental repair.
NECK: Neck supple, no palpable nodes.
CHEST: Lungs are clear.
HEART: Heart regular, not enlarged, no murmurs.
BREASTS: Normal.
ABDOMEN: Soft. No palpable masses.
PELVIC AND RECTAL: Not done.
ORTHOPEDIC: Examination of the left antecubital space reveals there is a generalized area of tender cellulitis with a moderate amount of swelling on the left as compared with the right.
X-RAYS
No x-rays are available for review.
DIAGNOSES
1. Chronic intravenous drug user.
2. Cellulitis, left arm.
PLAN
The patient should be admitted to the hospital for IV antibiotics and possible opening of the wound.
FOOTNOTE
Line 9 (Page 1). The street drug crank or speed is an amphetamine; not the same as crack (cocaine).
Line 12 (Page 1). The dictator changes Physical Examination to Past History
Line 13 (Page 1). The dictator changes using to shooting.
Lines 25-39 (Page 1). Some subheadings were added.
Line 45 (Page 1). Abbreviations in the Diagnosis or Impression should be expanded; thus, IV was expanded to intravenous.
Line 1 (Page 2). Alternative: I.V.
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