HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old man, originally from (XX), with a history of tuberculosis and lymphatic infection 11 years ago for which he completed treatment, who presents to the emergency department with 2-3 weeks of diffuse pruritic maculopapular rash.

Rash initially involved both hands, including palm area and neck, progressing to diffuse body rash, sparing facial area.  The patient reports no previous similar events.  He has been in contact with fiberglass particles at his construction work and used new cloth detergent approximately 2 weeks ago, which coincides with development of rash.

Denies fevers, chills, nausea, vomiting, diarrhea, dysuria, night sweats, loss of weight, decreased appetite, respiratory symptoms, sick contacts or travel.

He received prednisone 60 mg x1 and Benadryl 25 mg x1 in the emergency department with good symptomatic relief.

REVIEW OF SYSTEMS:  All other components of review of systems are negative or as described in history of present illness.

PAST MEDICAL HISTORY:  Mycobacterial infection treated 11 years ago, right foot surgery for removal of an accidentally included wood piece.

FAMILY HISTORY:  Father died of complications of asthma.

SOCIAL HISTORY:  Born in (XX), immigrated to the United States 7 years ago.  Lives in (XX).  Construction worker.  Denies drug, tobacco or alcohol use.  He is not sexually active.  Last sexual partner was approximately 2 years ago.  Reports consistent use of condoms.  No prior HIV test.  Vaccinations are up-to-date.

ALLERGIES:  No known drug or food allergies.

MEDICATIONS:  Prednisone 60 mg p.o. x1, Benadryl 25 mg p.o. x1.

PHYSICAL EXAMINATION:

GENERAL APPEARANCE:  Thin man, resting comfortably in bed, in no acute distress.

VITAL SIGNS:  Blood pressure 124/82, heart rate 60, respiratory rate 18, temperature 97.6 and pulse oximetry 100% on room air.

EYES:  No icterus.  Pink conjunctivae without petechia.

ENT:  Clear tympanic membranes and nasal turbinates and oropharynx.

NECK:  Bilateral neck fullness.  Supple.

LUNGS:  Clear to auscultation bilaterally.

HEART:  Regular rate and rhythm.  No murmurs, rubs or gallops.

ABDOMEN:  Nondistended, bowel sounds present, nontender and soft.  No organomegaly.

GENITOURINARY:  No open lesions.  Normal sized penis and testes.  No ureteral discharge.

LYMPH:  No neck, supraclavicular or axillary lymphadenopathy.

BACK:  No pain on palpation of vertebral processes or costovertebral angles.

MUSCULOSKELETAL:  No joint effusion, warmth.  Full range of motion throughout.

VASCULAR:  2+ throughout.

SKIN:  Dry skin with diffuse maculopapular rash and excoriation, sparing face.  No open lesions, ulcerations, scaling skin or discharge.

NEUROLOGICAL:  No gross neurological deficits.

PSYCHIATRIC:  Alert and active.  Appropriate.

LABORATORY DATA:  Sodium 131, potassium 3.8, chloride 102, CO2 31, anion gap 6, glucose 79, BUN 11, creatinine 0.89, calcium 9.0.  Total bilirubin is 0.5, AST 33, ALT 26, troponin 0.01, LDH 339, amylase 106.  WBC 3.1, hemoglobin 15.7, hematocrit 45.4, platelet 170,000, segmented cells 43, bands 2, lymphocytes 25, reactive lymphocytes 2 and eosinophils 17.

ASSESSMENT AND PLAN:  This is a (XX)-year-old gentleman with 2-3 weeks of diffuse erythematous maculopapular rash with facial sparing.  After carefully obtaining detailed history, he seems to have clear exposure to possible offending agents, including fiberglass, new detergent and possibly bed bugs.  Rash is consistent with an allergic dermatitis rather than an infectious process.  Although involvement of palms and soles can be seen in certain infectious process as syphilis and viral syndrome, we think history is more consistent with allergic reaction, which is supported by the presence of elevated eosinophils.  We think main therapy would consist of remove offending agents along with the application of topical steroid cream and antihistaminic therapy for symptomatic relief.  We agreed with RPR for evaluation of syphilis.

RECOMMENDATIONS:

1. Obtain RPR – syphilis IgE.
2. Remove offending agents.
3. Topical steroid cream and antihistaminic.
4. Follow up with primary care or Dermatology if no improvement in 1 week.

Thank you for this consultation.  Please contact infectious disease team if any questions or changes in the patient’s clinical status. Recommendations discussed with the emergency department team and handwritten note placed in the patient’s medical records.

DATE OF ADMISSION: MM/DD/YYYY

CHIEF COMPLAINT: Rapid heart rate.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who presents to the emergency department by squad. Apparently, just prior to arrival, he left work, was in his car, when his heart started racing. He states that he did have some chest tightness, 4/10 in intensity. No shortness of breath, nausea or vomiting. The patient states he had an ablation done in the past. He states he forgot to take his digoxin the last few days. He has never had a stress test.

PAST MEDICAL HISTORY:
1. SVT.
2. Hypertension.

MEDICATIONS:
1. Digoxin.
2. Toprol.

ALLERGIES: None.

SOCIAL HISTORY: The patient denies tobacco use. Occasionally, he drinks alcohol.

FAMILY HISTORY: The patient’s father has had a history of hypertension, and the patient’s grandmother has had a history of coronary artery disease.

REVIEW OF SYSTEMS: All systems are reviewed and otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: BP 152/108, temperature 98.4, pulse 190, respirations 18, O2 sat 98% on room air.
GENERAL: The patient is a well-developed male who appears anxious.
HEENT: Moist mucous membranes.
NECK: Supple, no JVD.
HEART: Tachycardic, otherwise regular rhythm, S1, S2.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Nontender, obese.
EXTREMITIES: No clubbing, cyanosis or edema.

LAB RESULTS: Chest x-ray shows no acute findings by my reading. EKG shows a supraventricular tachycardia with a rate of 190. No acute findings on reading. Troponin normal.

WBC 14.8, otherwise normal CBC. Digoxin level 0.5. Chem-7 is normal, except for a glucose of 118.

EMERGENCY DEPARTMENT COURSE: The patient was seen and examined. An IV was established in his left antecubital region. He was found to be in supraventricular tachycardia. He was given 6 mg of adenosine without conversion. He was given a repeat dose of 12 mg without conversion. He was bolused with Cardizem 20 mg and started on a drip at 15 mg an hour. He was rebolused with 25 mg of Cardizem. His rate began to come down into the 150s range and then he converted into a sinus rhythm. His old charts were reviewed. We did discuss the patient with Dr. John Doe, who is covering for his cardiology group, and the patient was discharged in good condition.

MEDICAL DECISION MAKING: The patient is a (XX)-year-old male with a supraventricular tachycardia. We will discharge him to home. He is to take his medications as directed. He is to follow up with his cardiologist and return if symptoms worsen.

DISPOSITION: Home.

DIAGNOSIS: Acute supraventricular tachycardia, resolved.

ER SOAP Note Sample #2

CHIEF COMPLAINT: Bilateral eye itching.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presents to the emergency department complaining of a 3-day history of eye itching and swelling. The patient states this started in her right eye 3 days ago and spread to her left eye yesterday. Today, both eyes have been bothering her. The patient states it is a little sore around her eyes, but her main complaint is that they are itchy. She has had some clear tearing but no purulent discharge. She states her right eye is a little bit more blurry than usual. She has no eye pain. No sneezing. No runny nose. She had similar symptoms to these a year ago. They were somewhat milder, and she did not seek medical attention. She denies any cough. She denies any pain with eye movement. She denies any foreign body sensation and denies any injury.

PAST MEDICAL HISTORY:
1. Diabetes.
2. Hypertension.

ALLERGIES: None.

CURRENT MEDICATIONS: Per medical reconciliation form.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Positive for one pack per day tobacco use, occasional alcohol use. Negative for illicit drug use.

REVIEW OF SYSTEMS: Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, visual disturbances, neck pain, chest pain, shortness of breath or abdominal pain. All other systems are negative, except as noted in the HPI.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 118/76, pulse 74, respiratory rate 18, temperature 98.4, pulse ox 98% on room air.
GENERAL: The patient is awake, alert and oriented, in no apparent distress, resting comfortably on the bed.
HEENT: Atraumatic and normocephalic. Pupils are equal, round, react to light. Extraocular movements are intact. Sclerae nonicteric. Conjunctivae are clear; although, she does have some clear chemosis present bilaterally. The patient has no pain with palpation over the globe itself. In her periorbital soft tissues, she has redness and swelling present, but it is not cellulitic redness; it is more of an irritated allergic reaction redness. She has no tenderness to palpation around her eyes. She has no purulent drainage. The oropharynx is clear. Pink and moist mucous membranes.
NECK: Supple, no lymphadenopathy, no thyromegaly. Trachea is midline.
LUNGS: Clear to auscultation bilaterally.
NEUROLOGIC: She is intact. Moving all four extremities symmetrically and spontaneously and following commands. Her left eye was tested. Visual acuity was tested and is 20/50. Her right eye visual acuity was 20/50 as well.
SKIN: Warm and dry. No evidence of rash other than is noted around the eyes.

LABORATORY RESULTS/RADIOLOGY: None.

EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. She remained hemodynamically stable throughout her stay. She received 50 mg of Benadryl and was discharged home.

MEDICAL DECISION MAKING: The patient presents with evidence of urticaria and allergic-related eye swelling. She has no evidence at this time of periorbital cellulitis, preseptal cellulitis or retro-orbital cellulitis. She has no evidence of ocular pain to suggest that she would have acute angle glaucoma. This would be unusual in both eyes anyway. She has no evidence of ruptured globe. No evidence of acute trauma and no evidence of cellulitis at this time. She is hemodynamically stable for discharge.

IMPRESSION: Urticaria.

PLAN:
1. The patient is to take Benadryl and Claritin as needed.
2. The patient is to follow up with her clinic, both for this and for medication refills that she is going to need in the near future.
3. She is to return for significant worsening of her symptoms, development of eye pain, worsening of her redness or swelling despite therapy or other concerns.
4. The patient verbalized understanding of the discharge instructions.

DISPOSITION: Discharged home in good condition.

ER SOAP Note Sample #3

SUBJECTIVE: The patient is without complaints, except he would like his baclofen pump addressed so that he can focus his attention on improving his functional abilities.

OBJECTIVE: The patient is afebrile with vital signs stable. The patient is 5 feet 8 inches tall and weighs 156 pounds. The head and neck are unremarkable. Pupils are equal, round, and reactive to light. Extraocular movements are intact. The patient is wearing eyeglasses. There is no apparent facial asymmetry. Heart and lung examinations are within normal limits. The abdomen is soft and nontender with active bowel sounds. A baclofen pump was noted in the left lower quadrant of the abdomen. Knee-high Ace wraps/compression stockings were in place.

ASSESSMENT AND PLAN:
1. Rehabilitation: A team conference was held today to review the patient’s functional goals and progress. The patient requires standby assistance with stand pivot transfers. The patient is independent with catheterization using a Coude catheter. Standby assistance/supervision is required for feeding, grooming, for bathing at the transfer tub bench, for upper extremity dressing, for bowel management, and for bed to wheelchair transfers. Minimal assistance is required for lower extremity dressing, bladder management, toilet transfers, and tub transfers. Based on the patient’s functional goals and progress, his tentative discharge date was established. The patient was told of this and was in agreement with the plan. However, he would like to focus on his baclofen pump for a portion of the rehabilitation stay. Continue comprehensive inpatient rehabilitation.
2. Spasticity: Under fair control. The neurologist will be contacted as far as further evaluation of the baclofen pump is concerned. A dye study is yet to be done.
3. Pain: Under fairly good control. Continue present management.
4. Bladder management: As previously mentioned, the patient is independent with intermittent catheterization. Continue present management.
5. Bowel management: Improving. Continue to work on a regulated program.
6. Hypertension: Under fair control. Continue present management.
7. Lower extremity edema: Improving. The lymphedema management team is assisting with his care.
8. Dementia: Workup in progress. The patient continues to be seen by the neurologist.

CHIEF COMPLAINT: Eye irritation.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old lady who comes to the emergency department complaining of eye irritation. She states that she was in a fight approximately three weeks ago, at which time she was scratched in her left eye. The patient presented to an outside hospital and was seen and evaluated for such. She was noted to have a corneal abrasion. She had followup with an ophthalmologist. She was seen by the ophthalmologist approximately six days ago and stated that everything was fine at that time. However, she woke up the next day, approximately five days ago, with irritation surrounding her left eye. She, therefore, came to the emergency department, was evaluated, and discharged home. She was given an ointment to place around her eye and told to return should she have worsening symptoms.

She states that it has been worsening. She complains of pain and redness surrounding her left eye. She describes the pain as a burning pain. It is approximately 6/10. It does not radiate. Nothing makes it better. Nothing makes it worse. She denies any blurry vision. She denies any other constitutional symptoms. No headache, no photophobia, no nausea, vomiting, fever, or chills. She denies vertigo.

PAST MEDICAL HISTORY: Depression, hypothyroidism, GERD, and fibromyalgia.

PAST SURGICAL HISTORY: Hysterectomy.

MEDICATIONS: Cymbalta, Synthroid, Protonix, Claritin, oxycodone, clindamycin, Benadryl, and bacitracin.

ALLERGIES: Morphine and penicillin.

REVIEW OF SYSTEMS: No fever, chills, sweats. No cough, cold, congestion. No change in vision or hearing. No one-sided numbness, weakness, tingling. No blackouts, no seizures. All other review of systems is negative.

SOCIAL HISTORY: No tobacco, no ethanol, no drugs. She does not work. She lives alone.

PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished (XX)-year-old Hispanic female who appears her stated age. She is awake, alert, and oriented x4. She was appropriate throughout the examination.
VITAL SIGNS: Blood pressure 138/100 mmHg, pulse 74 beats per minute, respirations 16 breaths per minute, temperature 97.4 degrees, and O2 sat 99% on room air.
HEENT: Pupils equal, round, and reactive to light. The left sclera is mildly injected. There is no purulent drainage noted. Extraocular motions are intact. Oral mucosa is moist and pink with no visible lesions. The patient has poor dentition.
NECK: Supple. No lymphadenopathy, no JVD, no carotid bruit.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended with positive bowel sounds.
EXTREMITIES: Without cyanosis, clubbing or edema. Pulses 3/4 throughout.
SKIN: Warm, dry and intact. She does have erythema surrounding her left eye. It is approximately 4.5-5 cm in diameter. There are no vesicular lesions. There are no purulent lesions.

EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING: The patient was evaluated by myself and Dr. John Doe. Visual acuity was tested. The patient was noted to be 20/40 in both of her eyes. Her left cornea was evaluated via fluorescein staining. The patient was noted to have no corneal defects. It was thought that her irritation may be secondary to the ointment that she is placing around her eye and therefore contact dermatitis. She was therefore advised to cease use of that.

The patient was given a prescription for Bactrim and told to return should she have worsening symptoms, severe pain, nausea, vomiting, fever, chills, numbness, tingling, weakness, dizziness, change in vision or other concerns. This does not appear to be a zoster at this point in time, given the fact that she has no vesicular lesions. There are no eschars, and it is a circumorbital lesion and does not appear to be restricted to one dermatome. The patient did understand reasons for which to return to the emergency department. She had no further questions.

ASSESSMENT: A (XX)-year-old Hispanic lady with contact dermatitis.

PLAN:
1. Discharge home.
2. Discontinue antibiotic ointment.
3. Continue clindamycin and Bactrim as prescribed.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who comes in via private vehicle. He states that two days ago he had what he describes as a small bump just anterior to his left ear. He states that over the last few days, this has expanded in size, and he is here for further evaluation. He states he did have a problem with “sores” in the past but not quite as big as the one he is complaining of currently.

The patient has a history of hepatitis C and, per the records, delusional parasitosis. He is denying any manipulation or picking to the area but does seem to be picking at other spots on his skin during history. He is denying any discharge or bleeding from his inner ear. He is denying any decreased hearing and has no pain over the site. He has had no fevers, chills, nausea or vomiting. He is denying any headache or dizziness. He is denying any hallucinations on examination.

PAST MEDICAL HISTORY: Hepatitis C, reflux. Per the records, he has a psychiatric history, but the patient denies this currently.

PAST SURGICAL HISTORY: The patient denies.

MEDICATIONS: Prilosec daily p.r.n. and ibuprofen p.r.n.

ALLERGIES: NONE.

SOCIAL HISTORY: The patient admits to smoking and denies any alcohol or drug use.

REVIEW OF SYSTEMS: Remaining review of systems reviewed and negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 35.6, pulse 86, respiratory rate 18, blood pressure 144/82, weight 168 pounds, height 5 feet 6 inches, and oxygen saturation 95% on room air.
GENERAL: The patient is alert, and he is oriented to where he is. He appears nontoxic. He is ambulatory with a steady gait.
HEENT: Head: Upon inspection, there are some small pinpoint areas of erythema and excoriation noted, but focused just anterior to his left ear shows an area approximately 6 cm oval that appears to be erythematous and has some dried blood surrounding the area but is not actively bleeding or having any discharge. There is some surrounding scab formation with honey-colored crust appearance, particularly over the inferior aspect. There are no sores or open wound to the posterior inner aspect of the ear. Note that there is no involvement to the forehead or the top of the scalp. His excoriations do not appear to be in a dermatomal distribution. Eyes: PERRL. Extraocular movements are intact. Sclerae and conjunctivae are clear. There is no injection, no tenderness over the globes. Ears: There is some cerumen impaction to the left ear, so we are unable to visualize the TM; however, there is no bleeding, discharge. There is no erythema or exudates of external canals. The internal ear canal appears to be intact. The surrounding pinna and tragus have no ulcers or sores and appeared to be having skin intact throughout. There is no tenderness to manipulation of the ear. The right ear TM is somewhat visible and appears to be intact and again no erythema, exudate, drainage, bleeding to the right ear. Nose: Nares are patent, no congestion. There is no tenderness. Oropharynx: Mucous membranes are moist and pink. No erythema or exudate of pharynx. No ulcers in the mucosal membranes.
NECK: Supple, no lymphadenopathy. He has full range of motion.
CHEST: Clear and equal breath sounds throughout.
HEART: Regular rate and rhythm.
NEUROLOGIC: The patient is alert and oriented. Cranial nerves II through XII are grossly intact.
SKIN: Again, there are randomly dispersed areas of small macules and papules that appear to be in various stages of healing where the patient seems to pick at them.

EMERGENCY DEPARTMENT COURSE: We did clean the wound just anterior to the left ear. We applied bacitracin and covered with a large Band-Aid. He was given Keflex 500 mg p.o. x2 and Bactrim DS 2 p.o.

ASSESSMENT:
1. Intertrigo to the left face.
2. History of hepatitis C.
3. History of delusional parasitosis.

PLAN:
1. Discharge the patient home.
2. Bactrim DS, Keflex, Atarax. Wash daily. Keep clean and dry. He is encouraged to use over-the-counter Neosporin ointment and keep it covered with a Band-Aid.
3. Return to the emergency room for any fever greater than 38, worsening signs and symptoms, increased redness, swelling, decreased hearing loss or any further concerns.
4. The patient is encouraged to follow up with his PCP this week to schedule an appointment.

CONDITION ON DISPOSITION: Stable.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who states he accidentally ate a cookie that had peanut butter encased within it. He states he is allergic to peanut butter. He took two Benadryl, total of 50 mg p.o., before arriving. He received an albuterol nebulizer. He states he consumed it around 20 minutes before arrival of EMS. He is having complaints of throat closure, chest tightness, shortness of breath, difficulty swallowing. No chest pain. No fever or chills. The patient is being seen for allergic reaction.

PAST MEDICAL HISTORY: Depression and anxiety.

PAST SURGICAL HISTORY: Negative.

MEDICATIONS: Klonopin, Abilify, Prozac, Tofranil, Wellbutrin.

ALLERGIES: NKDA, peanut butter.

SOCIAL HISTORY: Negative.

FAMILY HISTORY: Negative.

REVIEW OF SYSTEMS: As listed in the HPI. Remainder of ROS reviewed with the patient and negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 36.2, pulse 92, respiratory rate 22, blood pressure 104/72, and oxygen saturation 97% on room air.
GENERAL: The patient is an obese male who appears nontoxic and in no acute distress. No broken sentences. No dysphonia noted.
HEENT: Eyes: Pupils are equal and reactive. Extraocular muscles are intact. Accommodation is normal. Ears: No bulge and dullness. Nose: No mucosal congestion. Mouth and Oropharynx: Laryngeal edema and moist. No tonsillar edema, no exudate noted.
NECK: Supple. No JVD, adenopathy, bruit. No meningeal signs. No rigidity, no stridor.
CHEST: Clear. No rales, rhonchi or wheeze.
CARDIAC: Regular rate and rhythm. No murmurs, clicks, heaves or gallops.
ABDOMEN: Soft, nontender, nondistended.
SKIN: He has diffuse urticaria to the trunk and upper extremities, face and neck.
NEUROLOGICAL: Alert and oriented to time, place and person. Cranial nerves II-XII intact. Normal motor, normal sensory. Grip strength equal bilaterally.
EXTREMITIES: No cyanosis, no edema, no ecchymosis. Distal pulses, cap refill 2+ and equal bilaterally.
MENTAL STATUS: No suicidal or homicidal relations. Affect normal.

EMERGENCY DEPARTMENT COURSE AND TREATMENT: The patient received Solu-Medrol 125 mg IV in the emergency room, 50 mg of Benadryl IV, Pepcid 20 mg IV, epinephrine 1:1000, 0.3 mg subcutaneous. On two-view chest x-ray, no evidence of acute cardiopulmonary process. We visualized the films and agree with this interpretation. ED panel: Venous blood gas; pH 7.38, lactic acid 1.1, glucose 242, sodium 134, creatinine 1.3, ionized calcium 1.04, troponin 0.01, hemoglobin 16.8, hematocrit 50.4. EKG: Sinus rhythm, no ST elevation or depression noted, no change compared with prior study, rate 90, PR interval 142, QRS 110, QT 348, QTc 426, P axis 80, T axis is -5. Reassessed at 2000, improved. The uvula edema has improved as well. He states that his throat tightness and difficulty swallowing have improved. No chest tightness, shortness of breath or chest pain. We repeated Solu-Medrol 80 mg IV. CK is 2. CK-MB fraction is 2. Reassessed at 2130 hours. The rash had resolved. He had no complaints of chest tightness, throat closure, wheezing or shortness of breath. Prior to discharge, the patient was given prednisone 60 mg one p.o.

CONDITION ON DISPOSITION: Stable.

DIAGNOSES:
1. Allergic reaction secondary to peanut butter.
2. Hyperglycemia.

PLAN: The patient will be discharged with family. Medrol Dosepak as instructed. Atarax 25 mg three times daily as needed, #30, EpiPen use as directed, Zantac over-the-counter 150 mg twice daily for seven days. The patient is to return to the emergency room immediately if symptoms worsen.

CHIEF COMPLAINT: Right foot pain.

HISTORY OF PRESENT ILLNESS: The patient was running and playing football yesterday with some children and she felt an acute pain in her right heel. She states she has had this in the past. She was in the emergency room a couple of months back with similar symptoms. X-ray was done at that time and was read as negative for fracture. She has been better in the interim. However, she has not been completely asymptomatic. She states that she did not follow up with a primary care physician after being seen in the emergency room. She was given Percocet, which did provide temporary relief of symptoms; however, she never quite returned to normal afterwards. At this time, she has no numbness or tingling. She has no open areas, just the pain in the heel.

PAST MEDICAL HISTORY: Asthma. Bronchitis; she does take inhalers for this.

MEDICATIONS: Albuterol inhaler as needed.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient does smoke about a pack of cigarettes a day. No alcohol or illicit drug use.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: As mentioned, otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 104/68, pulse 82, respirations 18, and temperature 98.8.
GENERAL: The patient is awake, alert, and oriented, in no acute distress.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
MUSCULOSKELETAL: She has tenderness to palpation on the plantar surface of her right heel. She has full range of motion in her ankle. She has full range of motion in all of her toes. She has no appreciable numbness in the lower extremity. She has brisk cap refill. Peripheral pulses are intact. There is no evidence of bruising or swelling, no open areas, no lacerations.

EMERGENCY DEPARTMENT COURSE: This patient was seen for evaluation of her right foot pain. This seems to be a chronic and acute-on-chronic problem. She was seen here recently and had x-rays done. They are now available to view at this time. We did review the film. She does seem to have a large calcaneal spur, which is likely causing some degree of a plantar fasciitis. She has not taken anything for this at home. While she was here, we did arrange for podiatric followup. She is agreeable to this. She was given some exercises to do at home to flex the plantar surface of her foot. She was given Naprosyn to take for the pain.

DISCHARGE DIAGNOSES:
1. Foot pain.
2. Calcaneal spur.

PLAN:
1. The patient should follow up with podiatry as directed.
2. Naprosyn.
3. Stretching exercises.

DISPOSITION: The patient was discharged to home in stable condition.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female who presented to the emergency department complaining of a three-week history of itching spots all over, mainly her extremities and one on her abdomen, after moving into a women’s shelter. She states that she had been told that they had bed bugs at that location and they have been instructed to clean their sheets and clothes in hot water, which she has done. However, she does not think her roommates have been doing that. She denies any fevers, denies any new product exposure, and denies ever experiencing this before.

PAST MEDICAL HISTORY: Depression.

CURRENT MEDICATIONS: Zoloft and trazodone.

ALLERGIES: None.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Negative for tobacco, alcohol or drug use.

REVIEW OF SYSTEMS: Positive for chronic knee and back pain. Negative for fevers, chills, nausea, vomiting, diarrhea, constipation, headache, visual disturbances, neck pain, chest pain or shortness of breath. All other systems are negative, except as noted in the HPI.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 120/90, pulse 94, respiratory rate 18, temperature 97.4, and pulse ox 100% on room air.
GENERAL: The patient is awake, alert, and oriented, in no apparent distress, resting comfortably on the bed.
HEENT: Atraumatic and normocephalic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Sclerae are anicteric. Conjunctivae are clear. Oropharynx is clear with pink, moist mucous membranes.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, nontender, and nondistended. No masses, no hepatosplenomegaly.
SKIN: Warm and dry. No evidence of rash. She does have multiple, well-circumscribed circular areas of erythematous macules on mainly her upper and lower extremities and one on her abdomen, the largest of which is 1.5 cm in diameter. There is no significant induration and no tenderness in any of these areas.

LABORATORY RESULTS/RADIOLOGY: None.

EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated. She remained hemodynamically stable throughout her stay. She received 50 mg of Benadryl and instructions on cleaning her linens, clothes, and having her roommates do the same. She was given a prescription for Atarax and for Claritin and discharged home.

MEDICAL DECISION MAKING: The patient presented with evidence of urticaria, likely from bed bug bites. She has no evidence of scabies, no evidence of cellulitis, no evidence of any abscess. She is hemodynamically stable for discharge.

IMPRESSION:
1.  Urticaria.
2.  Bed bug bites.

PLAN:
1.  The patient is to take Atarax as needed for itching and Claritin as needed for itching.
2.  She is to return for worsening redness, purulent discharge, fever or other concerns.

The patient verbalized understanding of the discharge instructions.

DISPOSITION:  The patient was discharged to home in good condition.

HISTORY OF PRESENT ILLNESS: The patient has a one day history of intense right foot pain, some degree of swelling and erythema. This has happened to him once before. He thought it might have been gout. He did see a physician and has been taking some over-the-counter anti-inflammatories up to this point with some relief of symptoms. At this time, it did not give him any relief of symptoms whatsoever. The foot pain is quite intense. He is unable to walk on his own. He had to be basically carried into the emergency room.

PAST MEDICAL HISTORY: Hypercholesterolemia, some degree of gastroesophageal reflux disease, and possibly uric acid gout.

MEDICATIONS: Prilosec, Lipitor, and aspirin.

SOCIAL HISTORY: The patient does not smoke. No alcohol or illicit drug use.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: As mentioned, otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 106/76, pulse 88, respirations 12, temperature 97.2, and pulse ox 99%.
GENERAL: The patient is awake, alert, and oriented, in mild distress secondary to foot pain.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended with good bowel sounds with no organomegaly.
EXTREMITIES: The left foot is acutely tender to palpate along the first, second, and third metatarsals especially as well as the fourth and fifth. There is some tenderness to palpation in the first metatarsophalangeal joint. He does have good range of motion in his ankle. He does have limited range of motion in his first and second toes. His foot does feel warm to touch, not hot but warm.
NEUROLOGIC: Cranial nerves are intact. Reflexes are normal. Sensation is grossly intact.

EMERGENCY DEPARTMENT COURSE: The patient was treated in the emergency room for right foot pain. He was given Dilaudid for the pain. He was given a total of 4 mg on separate occasions. This did seem to relieve a lot of his symptoms. We did check a CBC, which showed a white count of 11.6. His uric acid was on the high side of normal at 8. His sed rate was 11. We discussed this case with Dr. John Doe who also evaluated the patient himself. It is an atypical presentation for gout. It is an atypical presentation for rheumatologic disease. The exact diagnosis is uncertain. He has seen a rheumatologist in the past and will pursue further diagnostic workup. He did leave the emergency room in stable condition with crutches on his own power though with much symptom relief.

DIAGNOSIS: Foot pain.

PLAN:
1.  At this time, we will give him Vicodin 1-2 tablets to take as needed for the pain.
2.  He can continue taking over-the-counter anti-inflammatories as necessary.

DISPOSITION:  The patient was discharged to home in stable condition.

CHIEF COMPLAINT: Right ankle pain.

HISTORY OF PRESENT ILLNESS: The patient presents to the emergency room for evaluation of about a two-week history of right ankle pain. He initially fell into a small ditch. He states that he initially injured his left ankle; however, this has improved over the last couple of weeks. The left ankle pain improved, and he started to develop right ankle pain about a week ago. This has increased in severity over the last couple of days. He has followed with his primary care doctor who has apparently treated him with antibiotics and pain medications. This has helped to some degree, but he continues to have increased redness, warmth, and pain in the left ankle. He has not felt ill. He has had no fevers, chills or sweats. He has pretty significant pain with any weightbearing.

PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. History of bypass.
3. History of heart failure.
4. Arthritis.
5. Some type of diabetes.
6. Hypercholesterolemia.

MEDICATIONS: Plavix, Proscar, Coreg, Lasix, Tricor, Coumadin, Lanoxin, Valium, Zocor, Vicodin, Proventil, and Amaryl.

The patient also has pills in his pocket; one says Percocet and one says Levaquin on it. He tells us that he has been taking these for the last several days.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient denies alcohol, tobacco or illicit drug use.

FAMILY HISTORY: Noncontributory.

REVIEW OF SYSTEMS: As mentioned, otherwise negative.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 132/66, pulse 68, respirations 18, and temperature 97.4.
GENERAL: The patient is awake, alert, and oriented, in no acute distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, reactive to light and accommodation. Extraocular movements are intact.
NECK: No lymphadenopathy. No carotid bruits. Neck veins are flat.
CHEST: Good breath sounds bilaterally with no wheezes, rales or rhonchi.
HEART: Regular rate and rhythm with no murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended. Good bowel sounds with no organomegaly.
EXTREMITIES: The patient has some increased warmth and redness on his left ankle, especially at the medial malleolus. He has only limited decreased range of motion in his left ankle. Range of motion in his toes and knee are normal. On the left, he has some swelling in the medial malleolar area as well. The right ankle appears normal and is normal with range of motion and palpation.

EMERGENCY DEPARTMENT COURSE: This patient was seen and evaluated for left ankle pain. It seems it has been going on for about two weeks and has had increasing symptoms within the last one week.

X-RAYS: X-ray of the ankle was done and was negative for acute fracture. It did show some soft tissue swelling at the area of the medial malleolus.

LABORATORY DATA: CBC was done and showed a white count of 11.8, H&H 14.6 and 44.6. BUN and creatinine were 42 and 2.2 respectively. His uric acid level was 9.1, which is high.

While he was still in the emergency room, we did speak with his primary care physician, as he was the one who sent him here to the emergency room and left a note to give him a call while the patient was still here. We did speak with him and filled him in on the radiologic and laboratory findings. He apparently was not given the patient’s history, whether the patient did not remember or it was not on his list we are not sure, but his primary care physician states that he had him on steroids recently in a rather big burst. He has been on pain medications and Levaquin for antibiotics. We decided to place him in a posterior splint and the primary care physician recommended Indocin for treatment of his gouty arthritis. We did fill him in on his creatinine being 2.2 and he was okay with that. He states that he will see the patient in followup.

DISCHARGE DIAGNOSIS: Acute gouty arthritis of the left ankle.

PLAN:
1. Indocin 25 mg three times a day until seen by primary care.
2. He should elevate the foot. He was placed in a dorsal splint. He is to maintain nonweightbearing status. We told this to him, as did the primary care physician apparently. However, the patient continues to try to weight bear when his family is not around. We gave him a quick low-purine diet and advised him to avoid alcohol, cheese, and other foods high in purines. He voices understanding. We told him to ask for more directions from his family doctor.

DISPOSITION: This patient was discharged to home in stable condition.

HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who complains of left foot pain for the past two days. The patient states he was playing soccer just before noticing the pain but does not recall any specific injury. The patient states the area has been erythematous and edematous, but he denies any numbness, tingling or weakness of his foot. He states the pain is not significantly worsened with walking. He states the pain is mostly over the first MTP joint. He has no previous history of gout.

PAST MEDICAL HISTORY: Chondromalacia.

MEDICATIONS: Ibuprofen and Tylenol.

ALLERGIES: None.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient denies tobacco or alcohol use.

REVIEW OF SYSTEMS: As above, otherwise negative per the patient.

PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 148/90, pulse 84, respirations 18, temperature 97.8 degrees, and O2 sat 99% on room air.
GENERAL: This is a well-developed, well-nourished male in no acute distress.
EXTREMITIES: The patient does have a warm, red, first MTP joint, which is more painful with dorsiflexion and plantarflexion of the toe. There is no other tenderness to palpation along the first metatarsal. There is no tenderness to palpation at the ankle. He has no other tenderness to palpation. There is no edema noted to the areas. He has full range of motion of the toes and ankle, 2+ pulses bilaterally.
NEUROLOGIC: The patient is oriented x4. Gross sensation is intact. Strength is 5/5 bilaterally.

EMERGENCY DEPARTMENT COURSE: The patient’s nursing notes and records were reviewed. The patient did receive 30 mg of Toradol IM for his pain.

MEDICAL DECISION MAKING: At this time, the patient does appear to have signs and symptoms of acute gouty arthritis. He does not have a history of gout, but the presentation of his first MTP is classic for podagra. Therefore, we will place the patient on a course of indomethacin and given him a list of clinics for followup.

DIAGNOSIS: Gout.

PLAN:
1. The patient was given indomethacin.
2. He is to rest, ice, and elevate.
3. Follow up with clinic of choice from the list provided.
4. Return to the ER for any increased pain, swelling, inability to walk or any other concerns.

DISPOSITION: The patient was discharged to home in good condition.