May 2, 2015
Patient is a 9 year old adolescent male, presents with a 2 day history of itching encrusted sores especially around the mouth area. Parent is using OTC antibiotic ointment with no improvement, no recent history of fever. Parent states that pat recently visited a petting zoo
HEENT are basically unrevealing. Temp in the office today is 98.4. The outer area of the mouth extending into the chin reveals macules, vesicles, copious purulent exudate forming honey- colored crust on a erythematous base. Skin on trunk, arms and legs is clear. No other symptomology
1. Rx for Mupirocin ointment applied to infected area TID.
2. Advised mom on proper hand washing technique.
3. To call if no significant improvement over the next 48 hours.
Leandro D. Cot, MD
LC: hpi d&t : 5/2/2015
Dermatology History and Physical (H&P)
May 2, 2015
This is a 45 year old male admitted via emergency department. He gives history of open ulcerations of both lower extremities of several weeks duration. A fever of unknown etiology for the last 48 hours
PAST MEDICAL HISTORY
Patient suffers from morbid obesity. He has known peripheral and arterial disease. His diabetes management is poor. He denies accidents or injuries to the lower extremities
He is disabled. No history of tobacco use
VITAL SIGNS: T 103.2, P 105, RSP 20, BP 155/95
GENERAL: Obese, English speaking Caucasian male
EENT: No gross abnormalities, Pupils restricted, poor dental hygiene
NECK: Neck supple. No palpable nodes
CHEST: Lungs are clear.
HEART: Heart is regular, no murmurs.
ABDOMEN: Soft with no palpable masses.
EXTREMITIES: Examination of the left lower extremity revealed a generalized area of tender cellulitis with a moderate amount of edema 1 to 2+ to the knees, with erythema and diffuse excoriation he has 4cm X 4cm superficial ulcer