History of Present Illness:
The patient is a
Past Medical History -reviewed
Past Surgical History - reviewed
Family History - reviewed
Social History - reviewed
Medication - Reviewed
Allergies - Reviewed
REVIEW OF SYSTEMS: All pertinent positives and negatives are stated in HPI and below, all other systems reviewed and are negative.
GENERAL: No malaise. No weight loss. No fever. No chills.
HEENT: No headache.
Eyes: No decreased vision.
Ears: No decreased hearing.
Nose: No bleeding.
Throat: No sore throat.
LUNGS: No shortness of breath. No cough. No COPD. No asthma.
CARDIAC: No chest pain. No palpitations. No orthopnea, no PND, no lower extremity edema.
GI: No Abdominal pain. No nausea. No vomiting. No constipation. No diarrhea. No change in weight. No change in appetite.
GU: No frequency. No hesitancy. No hematuria. No pyuria.
NEUROLOGIC: No dizziness. No neuropathy. No CVA. No headache.
MUSCULOSKELETAL: No neck pain or lower back pain.
Skin/Integuments - DESCRIPTION OF ABSCESS
Physical Examination
Vitals: Reviewed
GENERAL APPEARANCE: Patient is alert, awake, resting, talking in complete sentences with no acute distress.
HEENT: No facial trauma or abnormalities. No tonsillar hypertrophy, no uvula deviation. No tongue swelling.
NECK: Supple, no lymphadenopathy. Trachea midline. No mass. No JVD
LUNGS: Clear to auscultation bilaterally. Normal breath sound. No Wheezing, rales or rhonchi.
HEART: Auscultation: RRR. Normal heart sound. No Gallop. No Murmur or rubs.
Palpation: Normal cap refill. Normal skin turgor. No JVD. No Pedal edema
ABDOMEN: Normal bowel sounds. Soft, nontender, nondistended. No mass or hernia appreciated. No hepatosplenomegaly. No peritonitis
EXTREMITIES: Patient ambulatory. Good muscle tone. Moving all extremities equally. Good range of motion.
NEUROLOGIC: GCS 15. Patient is ambulatory with no gait abnormalities. Cranial 2-12 is grossly intact.
VASCULAR: Bilateral radial pulses, strong, equal.
SKIN: Description of abscess
PSYCH: normal mentation, awake, alert, not suicidal, not homicidal.
Imaging Results:
I have personally reviewed the imaging results
Labs/path:
I have personally reviewed the lab results
Assessments and Plans:
The patient is a
I have discussed with the patient the
diagnosis and findings.
I have also discussed with the patient the treatement
options including surgery and non-surgical options as well as alternatives.
For surgical procedure proposed, we discussed the risks which includes, but are not limited to, postoperative or chronic pain, bleeding, wound infection, hematoma, or need for further procedures or workup.
Other Complications may include deep vein thrombosis(blood clots), as well as other side effects affecting other organ systems such as the heart or lungs, and in rare circumstances, death as a result of the above complications.
The patient understand and agrees to proceed with the proposed procedure.
We also discussed that after debridement of the abscess, the wound may be left open for dressing changes