CHIEF COMPLAINT: Abscess behind the left ear.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic female with a history of several abscesses in the past, who presents with what she states is an abscess behind her left ear since yesterday. The patient also complains of two smaller bumps just inferior to this area. She denies any purulent drainage from any of the areas. She denies any fevers or chills. In addition, the patient complains of a pruritic rash to her arms for the last two weeks. The patient states that she has been using some new lotions and soaps, but this started after her rash developed.
PAST MEDICAL HISTORY: Depression.
MEDICATIONS: Depakote.
ALLERGIES: None.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: Noncontributory.
REVIEW OF SYSTEMS: As above. Otherwise, negative per the patient.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 112/66, pulse 72, respirations 18, temperature 98.2, and O2 sats 100% on room air.
GENERAL: This is a well-developed, well-nourished female, in no acute distress.
HEENT: Normocephalic and atraumatic. The patient does have a small, 0.5 cm in diameter pustule noted just posterior to her left pinna. There is erythema in this area, but there is no purulence noted. There is no fluctuance noted to the area. Just inferior to this, there is one small 0.25 cm in diameter area of induration noted under the skin, but there is no erythema or purulence noted to this area. Pupils are equally round and reactive to light and accommodation. Extraocular movements are intact.
NECK: Supple, no lymphadenopathy.
SKIN: The patient does have a maculopapular rash noted to the posterior aspects of both her forearms and upper arms bilaterally. There is no purulence noted in the areas. The areas are slightly erythematous, but they do blanch. Skin is, otherwise, warm and dry to touch. There are no other rashes noted.
EMERGENCY DEPARTMENT COURSE: The patient’s nursing notes were reviewed.
PROCEDURE NOTE: Using an 18 gauge needle, we did attempt to unroof the top of the pustule, which was successful, but there was no purulent drainage noted from the area. The patient was not able to tolerate pushing on the area due to the pain, and therefore, at this time, we will leave the area open to hopefully drain.
IMPRESSION AND MEDICAL DECISION MAKING: At this time, the patient does appear to have a small folliculitis or a small abscess to her posterior auricular area. We will place her on a course of Keflex. In addition, we will give her a prescription for hydrocortisone cream and Atarax for her rash. This appears to be most likely a contact dermatitis. There does not appear to be any evidence of any secondary infection to this area.
DIAGNOSES:
1. Abscess.
2. Dermatitis, not otherwise specified.
PLAN:
1. Prescriptions were written for hydrocortisone cream, Atarax, and Keflex.
2. The patient was instructed to apply warm compresses.
3. Follow up with primary care physician.
4. Return to the ER for any increased pain, swelling, fever or any other concerns.
DISPOSITION: The patient did leave prior to receiving her discharge instructions but was discharged to home in good condition.
