infectious disease

Pt seen w initial presentation of local erythema, warmth, swelling to ____. Sensitivity/pain to light touch around the erythematous area. Nontoxic appearing, VSS. No lymphangitic spread visible and no fluid pockets or fluctuance c/f abscess noted. Low c/f osteomyelitis or DVT. No immune compromise, bullae, pain out of proportion, or rapid progression c/f necrotizing fasciitis. No purulence, penetrating trauma, known MRSA colonization, IV drug use, or SIRS c/f MRSA infection. No h/o prior tx failure, fever, chronic leg ulcers, chronic edema/lyphedema c/f treatment failure. Plan tx w Reflex 500mg PO q8hrs outpt. Erythema outlined. DC home w return precautions discussed

Take all of your antibiotics as ordered. Please call your primary care doctor within 2 days of discharge and follow-up with them in one week. If the affected cellulitic area increases in redness, warmth, pain or swelling call your primary care doctor. If you develop fever, chills, and/or malaise, call your primary care doctor.

Will empirically treat for GC/Chlamydia with Ceftriaxone IM and Azithromycin. GC culture sent. Abstinence and safe sex precautions were provided and the patient demonstrated understanding.