Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on August 17, 2023 14:44   Verified By: MD on August 17, 2023 15:16    Encounter Info: Hospital, Observation, 08/17/23 -     * Final Report *          History of Present Illness/Subjective      Chief complaint: Insect bite  HPI: Patient is a 35-year-old male patient with no previous medical history presents to emergency department with increased swelling and redness to his lower abdomen and genitals.  He was seen 3 days prior in the same emergency department and diagnosed with mild cellulitis around what he describes as a bug bite.  He noticed a pustule and used a screw to drain it.  He has been taking cephalexin and Bactrim as prescribed but not getting any better he did have a fever of 101 3 days ago when he was in the emergency room denies any history of diabetes smokes 1 pack/day.  Upon evaluation in the emergency room today patient's vitals are stable no tachycardia no tachypnea no fever White count is normal CMP is normal and a CT abdomen pelvis with IV contrast was obtained that showed 1.4 x 1 cm subcutaneous abscess in the lower anterior abdominal wall as described.  Cellulitis in the anterior soft tissue of the lower abdomen wall extending from level of the iliac crest to the base of the penis.  Case was discussed with Dr.  surgeon who felt patient only needed IV antibiotics.  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.4 °C (Oral)  BP: 100/66  HR: 80 (Peripheral)  RR: 18  SpO2: 100%  Oxygen Therapy: Room air  WT: 106.80 kg   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    106.8 kg    08/17/23    Patient Height  Current Height:    180.3 cm    08/17/23        General: Alert and oriented, No Acute distress Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic, atraumatic Neck: Supple, normal range of motion, no nuchal rigidity Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. No added sounds Cardiovascular: Normal rate, Regular rhythm. s1 s2 positive Gastrointestinal: Soft, Non-tender. BS present all 4 quadrants, no rebound tenderness Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, no obvious rashes, cellulitis in groin, see picture Neurologic: No focal weakness. Sensation intact. Normal mood and affect. cranial nerves grossly intact.  Images   abd cellulitis abd cellulitis      Assessment/Plan       1. Abdominal wall cellulitis   L03.311   Worsening cellulitis despite use of oral medications warrants inpatient IV antibiotics.  -Follow-up on cultures.  -Start patient on broad-spectrum antibiotics  -Pharmacy to dose vancomycin.   2. Abscess   L02.91   Noted.  At this time does not need drainage   3. Therapy failure due to antibiotic resistance   Z16.20   Noted.    Code Status   None Recorded   Chronic Problem List    Tobacco use  Procedure/Surgical History  ?BILAT LEG ?BRAIN SURGERY (BLOOD CLOT REMOVAL)     Medications   Home Medications (2) Active  Bactrim DS 800 mg-160 mg oral tablet 1 Tablet, Orally, BID  Keflex 500 mg oral capsule 500 mg = 1 Capsule, Orally, 4 Times Daily  Active Scheduled Inpatient Medications  piperacillin-tazobactam, Injection, 3.375 GM, IVPB, ONCE, Indication: SSTI - Severe/DFI/Necrotizing Fasciitis, Start: 08/17/23 15:00:00    One-Time Medications Given 08/16/23 00:00:00 TO 08/17/23 14:44:30  ketoROLAC, Injection, 30 mg, IV Push, ONCE, (1 DOSE 08/17/23 10:44:00)  Lactated Ringers (Lactated Ringers Bolus), Infusion, 3,000 mL, IVPB, ONCE, (1 DOSE 08/17/23 11:22:00)  morphine (morphine inj ED), Injection, 4 mg, IV Push, ONCE, (1 DOSE 08/17/23 10:44:00)  morphine (morphine inj ED (doses 5 mg - 10 mg)), Injection, 6 mg, IV Push, ONCE, (1 DOSE 08/17/23 12:27:00)  piperacillin-tazobactam, Injection, 4.5 GM, IV Push, ONCE, (1 DOSE 08/17/23 10:44:00)  vancomycin, Injection, 2 GM, IVPB, ONCE, (1 DOSE 08/17/23 11:16:00)  PRN Medications (0600 - 0559) from 08/16 - 08/17  Lactated Ringers, 1,000 mL, IVPB, Unscheduled, 0  Dose(s)   morphine, 6 mg, IV Push, Q10min, 0  Dose(s)   Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use 1-25 inhales/day.   Home/Environment   motel, Lives with Alone.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.7 k/cumm (08/17/23 10:55:00)  RBC: 4.27 million/cumm (08/17/23 10:55:00)  Hgb: 13 GM/dL Low (08/17/23 10:55:00)  Hct: 38.3 % Low (08/17/23 10:55:00)  MCV: 90 fL (08/17/23 10:55:00)  MCH: 30.5 pg (08/17/23 10:55:00)  MCHC: 34 GM/dL (08/17/23 10:55:00)  RDW: 13.1 % (08/17/23 10:55:00)  Platelet: 221 k/cumm (08/17/23 10:55:00)  MPV: 7.7 fL (08/17/23 10:55:00)  Neutrophils %: 72 % (08/17/23 10:55:00)  Lymphocytes %: 15 % (08/17/23 10:55:00)  Monocytes %: 8 % (08/17/23 10:55:00)  Eosinophils %: 3 % (08/17/23 10:55:00)  Basophils %: 0 % (08/17/23 10:55:00)  Absolute Neutrophil: 7.1 k/cumm (08/17/23 10:55:00)  Absolute Lymphocyte: 1.5 k/cumm (08/17/23 10:55:00)  Absolute Monocyte: 0.8 k/cumm (08/17/23 10:55:00)  Absolute Eosinophil: 0.3 k/cumm (08/17/23 10:55:00)  Absolute Basophil: 0 k/cumm (08/17/23 10:55:00)  Chemistry:  Sodium SerPl QN: 134 mmol/L Low (08/17/23 10:55:00)  Potassium SerPl QN: 3.9 mmol/L (08/17/23 10:55:00)  Chloride SerPl QN: 100 mmol/L (08/17/23 10:55:00)  Carbon Dioxide SerPl QN: 28 mmol/L (08/17/23 10:55:00)  Anion Gap: 6 mmol/L (08/17/23 10:55:00)  BUN SerPl QN: 7 mg/dL (08/17/23 10:55:00)  Creatinine SerPl QN: 0.79 mg/dL Low (08/17/23 10:55:00)  Estimated GFR (CKD-EPI, no race): >90 (08/17/23 10:55:00)  Estimated CRCL (CG): >120 (08/17/23 10:55:00)  Glucose SerPl QN: 86 mg/dL (08/17/23 10:55:00)  Calcium Total SerPl QN: 8.7 mg/dL (08/17/23 10:55:00)  Phosphorus SerPl QN: 2.2 mg/dL Low (08/17/23 10:55:00)  Alkaline Phos SerPl QN: 83 Units/L (08/17/23 10:55:00)  ALT SerPl QN: 18 Units/L (08/17/23 10:55:00)  AST SerPl QN: 20 Units/L (08/17/23 10:55:00)  Bilirubin Total SerPl QN: 0.5 mg/dL (08/17/23 10:55:00)  Total Protein SerPl QN: 6.7 GM/dL (08/17/23 10:55:00)  Albumin SerPl QN: 3.7 GM/dL (08/17/23 10:55:00)  Magnesium SerPl QN: 1.9 mg/dL (08/17/23 10:55:00)  Lactate Venous Pl QN: 0.9 mmol/L (08/17/23 10:55:00)  Urine Studies:  Color: Light-Yellow (08/17/23 11:24:00)  Clarity: Clear (08/17/23 11:24:00)  Specific Gravity: 1.015 (08/17/23 11:24:00)  pH: 6.5 (08/17/23 11:24:00)  Protein: NEGATIVE (08/17/23 11:24:00)  Glucose: Normal (08/17/23 11:24:00)  Ketones: NEGATIVE (08/17/23 11:24:00)  Bilirubin: NEGATIVE (08/17/23 11:24:00)  Hgb Ur: NEGATIVE (08/17/23 11:24:00)  Nitrite: NEGATIVE (08/17/23 11:24:00)  Urobilinogen: Normal (08/17/23 11:24:00)  Leukocyte Esterase Ur: NEGATIVE (08/17/23 11:24:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (08/17/23 10:55:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (08/17/23 10:55:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 08/17/2023 12:16 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  1.4 x 1.0 cm subcutaneous abscess in the lower anterior abdominalwall as described above.2.  Cellulitis in the anterior soft tissues of the lower abdominalwall extending from the level of the iliac crest to the base of thepenis.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 08/17/23 15:16 ________________________________________________________ MD