Age: 70.0
Sex: M
Vaccine: COVID19
Symptoms: Wound, X-ray limb normal
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: MD on February 13, 2021 12:02   Verified By: MD on February 13, 2021 16:48   Encounter Info: Hospital, Observation, 02/13/21 - 02/15/21    * Final Report *        Basic Information  Time Seen: MD / 02/13/2021 10:37     Chief Complaint  Foot pain-swelling (Complaint of)  History of Present Illness      Patient presents to the emergency department continuing to complain of some left foot pain and swelling.  The patient was seen here on February 11, 2021.  An x-ray at that time was negative.  The patient was started on cephalexin for some erythema and infection over his left heel.  Patient states that this has continued to worsen.  Patient states that his wife has been "digging" at it and trying to squeeze infection out of it.  Patient states he has been taking is not helping.  Patient states that this is very painful.  Patient denies any fever, chills, problems with his chest, abdomen, urine or other extremities.     Review of Systems     The eleven point review of systems is negative other than symptoms/problems mentioned in the HPI.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.6 DegC  Heart Rate:       72 bpm  Resp Rate:       16 br/min  BP #1:       128 / 81 mmHg  SpO2 (%):       98 %  O2 Device:       Room air     Weight KG: 82.2 kg     Constitutional:  No acute distress,  well-nourished HEENT:  throat normal  TMS normal Nose no congestion moist mucous membranes Respiratory:  Lungs CTA bilaterally  nonlabored non tachypneic Cardiovascular:  Regular rate and rhythmno edema Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  no deformity, tenderness or swelling Skin:  Heel of left foot:  area if swelling and erythema 11x13cm with central open area; no drainage able to be expressed; tender.  See picture in Clinical Media. Neurologic:  Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psych:  cooperative; appropriate mood and affect                 Condition     Condition: Stable  Admission  02/13/21 12:02:13 Obs Physician:  Dr.   Assessment/Plan       1. Cellulitis of foot   L03.119    2. Puncture wound of foot   S91.339A    Orders:   ketoROLAC, 15 mg, IV Push, Injection, ONCE, NOW, 02/13/21 11:59:00, 02/13/21 11:59:00   piperacillin-tazobactam, 3.375 GM, IVPB, Injection, ONCE, 02/13/21 16:00:00, 02/13/21 16:00:00   piperacillin-tazobactam, 4.5 GM, IV Push, Injection, ONCE, STAT, 02/13/21 12:00:00, 02/13/21 12:00:00       MCV  02/13/21 10:55   80  Low   08/12/20  82          MCH  02/13/21 10:55   26.5  Low   08/12/20  27.2          MCHC  02/13/21 10:55  33.0   08/12/20  33.1          RDW  02/13/21 10:55   16.5  High   08/12/20   14.7  High          Platelet  02/13/21 10:55  328   08/12/20  268          MPV  02/13/21 10:55   6.9  Low   08/12/20   6.9  Low          Neutrophils %  02/13/21 10:55  81   08/12/20  78          Lymphocytes %  02/13/21 10:55  9   08/12/20  14          Monocytes %  02/13/21 10:55  7   08/12/20  7          Eosinophils %  02/13/21 10:55  3   08/12/20  1          Basophils %  02/13/21 10:55  1   08/12/20  1          Absolute Neutrophil  02/13/21 10:55   10.7  High   08/12/20  6.6          Absolute Lymphocyte  02/13/21 10:55  1.2   08/12/20  1.1          Absolute Monocyte  02/13/21 10:55  0.9   08/12/20  0.6          Absolute Eosinophil  02/13/21 10:55   0.4  High   08/12/20  0.1          Absolute Basophil  02/13/21 10:55  0.1   08/12/20  0.0              Routine Serum/Plasma Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  02/13/21 10:55  135   08/12/20  138          Potassium SerPl QN  02/13/21 10:55  4.2   08/12/20  3.6          Chloride SerPl QN  02/13/21 10:55  100   08/12/20  100          Carbon Dioxide SerPl QN  02/13/21 10:55  25   08/12/20  26          Anion Gap  02/13/21 10:55  10   08/12/20   12  High          BUN SerPl QN  02/13/21 10:55  15   08/12/20  7          Creatinine SerPl QN  02/13/21 10:55   0.60  Low   08/12/20   0.72  Low          Estimated GFR (CKD-EPI)  02/13/21 10:55  >90   08/12/20  >90          Glucose SerPl QN  02/13/21 10:55  99   08/12/20  94          Calcium Total SerPl QN  02/13/21 10:55  9.1   08/12/20  9.3          Alkaline Phos SerPl QN  02/13/21 10:55  62   08/12/20  59          ALT SerPl QN  02/13/21 10:55   6  Low   08/12/20  8          AST SerPl QN  02/13/21 10:55   9  Low   08/12/20   12  Low          Bilirubin Total SerPl QN  02/13/21 10:55  0.3   08/12/20  0.6          Total Protein SerPl QN  02/13/21 10:55   8.1  High   08/12/20  7.8          Albumin SerPl QN  02/13/21 10:55  3.9   08/12/20  4.0          Lactate Venous Pl QN  02/13/21 10:55  0.7   08/12/20  0.8      Diagnostic Results  No qualifying data available.        Signature Line Electronically Signed on 02/13/21 16:48 ________________________________________________________ MD