CHIEF COMPLAINT: Toe pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old alcoholic male who presents to the emergency department today complaining of pain in his right fifth toe. He reports that one year ago he stubbed it. The patient believes he may have a piece of wood inside there as well. He reports he got his tetanus immunization less than three years ago. Last evening, he was at the drop-in center where he saw Dr. John Doe, he says, who did incision and drainage of the toe without anesthetic in attempt to find the foreign body. Apparently, he was unable to locate such foreign body, and he came to us today complaining of the above pain. He is denying fevers, chills, nausea or vomiting. The patient does report pain in the foot. He has been drinking heavily today.
PAST MEDICAL/SURGICAL HISTORY: Alcoholism. Other than that, negative.
ALLERGIES: None.
MEDICATIONS: None.
SOCIAL HISTORY: The patient smokes tobacco, drinks alcohol, denies IV drugs currently, and has a history of cocaine use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: No fevers, chills, nausea or vomiting. He does report toe pain. Further review of systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 128/78, pulse 116, respiratory rate 20, temperature 97.8, and O2 sat 97% on room air.
GENERAL: The patient is in no acute distress. Alert, oriented, and intoxicated.
HEENT: Normocephalic and atraumatic. Extraocular movements are intact.
NECK: Supple.
LUNGS: Respirations unlabored.
HEART: Normal S1, S2. Rate of 90.
ABDOMEN: Soft, nontender, and nondistended.
GENITOURINARY: Deferred.
MUSCULOSKELETAL: Moves all extremities equally. His right fifth toe has an incision on the medial aspect, which does not appear significantly infected. Toe is somewhat indurated. There is no purulent drainage from it. It is otherwise clean. The skin is somewhat erythematous around the toe.
NEUROLOGIC: Cranial nerves II through XII intact.
PSYCHIATRIC: Affect appropriate.
LAB RESULTS/RADIOLOGY: None.
CONSULTATIONS: None.
EMERGENCY DEPARTMENT COURSE: The patient presented to the emergency department with a chief complaint and history of present illness as above. He was evaluated. He had an x-ray of his foot, which demonstrated no foreign body, no fractures. We examined the toe. He did have a small laceration, which appears to have been an incision. It is a clean laceration. Nonetheless, we believe he may be developing an early cellulitis. We prescribed Keflex for the patient. We gave him two Percocet p.o. here in the ED and discharged home with a prescription for ibuprofen as well as Keflex for five days. The patient was instructed to follow up with his primary doctor. Return if worse.
DIAGNOSIS: Right-sided toe pain.
CONDITION: Good.
DISPOSITION: The patient was discharged to home.
