CHIEF COMPLAINT: Difficulty swallowing.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who apparently, for the last 4 days, has had a little bit of neck pain and difficulty swallowing. It started out mostly as left posterior neck pain and left submandibular area pain.
She saw her primary care physician initially and was placed on Amoxil 875 t.i.d. She thought this possibly could be early peritonsillar abscess or possibly even an abscessed tooth. The patient states that she has not gotten much better in the last couple of days. She continues to have some trouble swallowing and has quite a bit of pain.
Apparently, after consulting with her family physician again, a CT scan of the neck was obtained earlier today. After the results of this were available, the patient was told to come to the emergency department for further evaluation and treatment.
The CT scan of the neck revealed findings that are concordant with a left peritonsillar cellulitis without any signs of any abscess.
PAST MEDICAL HISTORY: No diabetes, cardiac or respiratory problem.
CURRENT MEDICATIONS:
1. Claritin-D.
2. Albuterol.
3. Zyrtec.
4. Amoxicillin.
MEDICATION ALLERGIES: None.
SOCIAL HISTORY: The patient does smoke. She does not drink.
REVIEW OF SYSTEMS: Negative at this time.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 130/82. Temperature 97.2. Pulse 94. Respirations 16. O2 saturation is 99%.
HEENT: Head is normocephalic. TMs are okay. Nose is clear. Throat: There is a little bit of erythema noted. It is more prominent on the left than the right. No exudate. There are no signs of abscess clinically. There is a small submandibular node on the left. She has no posterior adenopathy.
HEART: Regular rhythm and rate.
LUNGS: Clear.
ABDOMEN: Soft.
EMERGENCY DEPARTMENT COURSE: While in the emergency department, the patient did receive 10 of Decadron IM and a small amount of morphine, Phenergan and a liter of normal saline. She received 600 mg of IV clindamycin. This case was discussed with Dr. John Doe. He will be glad to follow her in the next couple of days.
We do not think the patient needs to be admitted. She is taking clears without much problem. There are no clinical signs of abscess. The CT scan reveals only cellulitis. Her Amoxil will be withheld. She will be started on clindamycin 300 q.i.d. for the next week. Lortab 5 as needed for pain. No work for the next few days.
DIAGNOSIS: Acute peritonsillar cellulitis, left greater than right.
PLAN: As above mentioned.
DISPOSITION: Discharged.
