kansasrhit2009
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S: Pt presents at this time after hooking his hand on a wheelbarrow. It caught the webbing between his thumb and first finger. He believes that this happened 3-4 days ago. It is now getting red and swollen and is oozing a little bit of serosanguineous fluid.
O: There is an irregular previous laceration in the webspace between thumb and first finger and it is now erythematous and puffy. It is draining a little serosanguineous fluid but nothing purulent. Erythema extends to the dorsum of his hand somewhat.
A: 1. SECONDARILY INFECTED WOUND OF LEFT HAND
P: We will treat now with Duricef 500 mg b.i.d. for 10 days. Bactroban ointment to be applied after soaking in Epsom Salt and cleansing well with Hibiclens. Patient is to keep it up and elevated as much as possible. We will recheck it in a week. Patient does have a history of CLL and does not remember his last tetanus shot so Tdap is given at this time. Patient is to watch for any progression of erythema or swelling. F/u sooner if having more trouble. He denies any fevers at this time.
Thank you
O: There is an irregular previous laceration in the webspace between thumb and first finger and it is now erythematous and puffy. It is draining a little serosanguineous fluid but nothing purulent. Erythema extends to the dorsum of his hand somewhat.
A: 1. SECONDARILY INFECTED WOUND OF LEFT HAND
P: We will treat now with Duricef 500 mg b.i.d. for 10 days. Bactroban ointment to be applied after soaking in Epsom Salt and cleansing well with Hibiclens. Patient is to keep it up and elevated as much as possible. We will recheck it in a week. Patient does have a history of CLL and does not remember his last tetanus shot so Tdap is given at this time. Patient is to watch for any progression of erythema or swelling. F/u sooner if having more trouble. He denies any fevers at this time.
Thank you