Spider Bite ER Medical Transcription Sample Report
CHIEF COMPLAINT: Spider bite, left knee.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who comes to the emergency department complaining of a spider bite to his left knee. The spider bite has been there for several weeks.
He has had one abscess to his chest that he has cut open several times himself and has had drain copious amounts at a time but this is actually healed over. There is one area on his leg that is healing, but the area on his right knee is red, draining and very painful.
He denies any fevers. He says it hurts when he stands and walks. This all started with the abscess on his chest. He says that now he has had these areas on his legs. He is not sure how they are happening.
Pain is 10/10. Nursing notes reviewed.
REVIEW OF SYSTEMS: He denies weakness, numbness or tingling. Review of systems otherwise negative.
PAST MEDICAL HISTORY: None.
ALLERGIES: None.
CURRENT MEDICATIONS: None.
IMMUNIZATIONS: Up to date.
SOCIAL HISTORY: He does smoke one pack of cigarettes a day.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8, pulse 68, respirations 18, blood pressure 106/82, pulse 97%.
GENERAL: Well-appearing, nontoxic (XX)-year-old male. He is alert. He is oriented x3. He is calm and cooperative during exam.
EXTREMITIES: Over the right knee, this is over the inferior portion over the proximal tibia, there is an abscess. This is open and draining. There is an area of surrounding cellulitis, very tender to palpation. Full range of motion of the knee with very minimal pain over the medial aspect of the knee. There is a healing abscess in the left lower extremity. There is a healed abscess over the left chest right along the left nipple.
DIAGNOSTICS: None.
PROCEDURE: The area was prepped with Betadine, infiltrated with total of 9 mL bupivacaine without epinephrine with good results. The area was opened further with an 11 blade. Hemostats were inserted in the wound to break up loculated fluid and debride this area. Unfortunately, this was not able to be packed. The area was bandaged.
MEDICAL DECISION MAKING: The patient has cut this open several times. This is open and draining. This was attempted to be opened further by myself. The whole top of this was basically opened up. Therefore, there is no packing that was able to be placed.
IMPRESSION:
1. Left knee draining abscess.
2. Resolving left knee and left chest abscess.
DISCHARGE INSTRUCTIONS:
1. Follow up with medicine on-call in 2 days for wound check.
2. Return for pain, redness and swelling.
3. Wound care instructions.
4. Bactrim DS 2 p.o. b.i.d. x10 days.
5. Vicodin, total of 15 tablets.
