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PATIENT PRESENTATION

Chief Complaint

“I fell while hiking this weekend and now my arm has really a painful blister.”

History of Present Illness

SP is a 36-year-old woman who presents to the emergency room of her local hospital 3 days after falling during a hike and sustaining an injury to her right upper extremity. She has a few scratches on her right lower extremity, but no punctures to the skin, scabs, or blisters. She has been taking acetaminophen 500 mg a few times per day since the fall, but states that it hasn’t helped much. She also states that she washed the wound when she got home with soap and water, but didn’t use hydrogen peroxide or apply any topical antibiotics.

Past Medical History

Seasonal allergies

Surgical History

None

Family History

Mother with hypertension

Father with diabetes

Maternal grandfather with heart failure

Social History

No illicit drug use

No tobacco use

Occasional alcohol use (2 to 3 times per month)

Allergies

NKDA

Home Medications

Ethinyl estradiol and norgestimate (Sprintec), 1 tablet by mouth daily

Fexofenadine (Allegra) 180 mg by mouth daily for allergies

Fluticasone (Flonase) nasal spray, one spray in each nostril twice daily during allergy season

Vitals on Admission

Temp 39.5°C, BP 111/54 mm Hg, P 86, RR 16 breaths per minute, Wt 57.5 kg, Ht 5′5″

Physical Examination

General

Well-developed, well-nourished appearing Caucasian woman in no acute distress

Skin

Right upper arm: red, erythematous, warm, and tender to touch; localized fluid collection that appears fluctuant

HEENT

PERRLA; EOMI, oropharynx clear

Neck/Lymph Nodes

Supple, no lymphadenopathy

Lungs/Thorax

Clear to auscultation, no rales or wheezing

Cardiovascular

Regular rate/rhythm, no murmurs/rubs/gallops

Abdomen

Soft, NT/ND; (+) Bowel sounds

Genitourinary/Rectal

No observed abnormalities

Musculoskeletal/Extremities

Upper extremities: erythematous area on RUE with 2 × 3 cm abscess that is painful to touch

Lower extremities: no observed abnormalities

Neurologic

A & O ×3

Imaging

X-ray of RUE: diffuse soft tissue swelling of upper arm; no subcutaneous gas or foreign body; no fractures

Laboratory ...

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