CHIEF COMPLAINT: Abdominal wound bleeding.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who underwent a tubal ligation two days ago. The patient states that the wound was healing well, and she was having decreased pain until earlier this morning when she states she began having some pus and bloody drainage from her incision site. The patient states the area has been painful and has been slightly erythematous. She denies any edema. She denies any fever or chills.
PAST MEDICAL HISTORY: Hypertension and diabetes, which is diet controlled.
MEDICATIONS: Lisinopril and ibuprofen.
ALLERGIES: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient smokes half pack of cigarettes a day. She denies alcohol or illicit drug use.
REVIEW OF SYSTEMS: As above, otherwise negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 148/102, pulse 86, respirations 18, temperature 97.8, and O2 sat 98% on room air.
GENERAL: This is a well-developed, well-nourished female in no acute distress.
HEART: Regular rate and rhythm. No murmurs, gallops or rubs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: The patient does have a wound and the incision site in her inferior umbilicus that is covered with Dermabond. There is a small area of purulence noted at the wound site. There is no fluctuance or induration noted to the wound site. She does have a small amount of erythema surrounding the incision site. The abdomen is otherwise soft, nontender, and nondistended. Bowel sounds x4.
SKIN: Warm and dry to touch.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING: The patient’s nursing notes were reviewed. We did give the patient 500 mg of Keflex p.o. as her initial dose here. At this time, the patient does appear to have a superficial wound infection. There does not appear to be any abscess, and she does not have a significant amount of cellulitis. At this time, we will place the patient on a course of Keflex and have her follow up with her OB/GYN.
DIAGNOSIS: Abdominal cellulitis.
PLAN:
1. The patient is given Keflex 500 mg q.i.d. x5 days.
2. She is to follow up with her doctor.
3. Return to the ER for any increased pain, redness, swelling, fever or any other concerns.
DISPOSITION: The patient was discharged to home in good condition.
