A patient with uncomplicated right foot cellulitis
CC: “My right foot hurts”
Reason for consult : Evaluation and management of possible new onset CHF
Requesting physician : John Doe, MD
HPI :The patient is a 45 year old homeless man who cut his right foot on a piece of glass about three days ago. He has noted increasing pain and swelling as well as stiffness in his right foot over the past 24 hours. The pain is described as a “burning” sensation.
ROS
Constitutional - Positive for subjective fevers and chills
Musculoskeleta - Negative for joint pain or stiffness in his right lower extremity
Pulmonary - Positive for intermittent non-productive cough
Pertinent PFSH is remarkable for ongoing alcohol and tobacco abuse
General: Unkempt white male who looks older than stated age; NAD
Vitals: 120/80, 72, 100.0
Eyes: anicteric sclerae with moist conjunctivae
Oropharynx: Clear with MMM and no erythema; poor dentition with multiple caries and missing. teeth
Lungs: CTA
. CV: RRR without MRGs . Abdomen: Soft, non-tender, no HSM
Extremities: Right foot shows swelling from the ankle to the knee; no pain to palpation in either
joint; FROM; no extremity edema on the left
