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Dr.Wagner -> RE: October case #1 (October 13, 2007 11:43:26 AM)
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On physical examination, the patient’s temperature is 98.96°F(37.20°C), with a blood pressure of 129/67 mm Hg and a heart rate of 89 bpm. His respiratory rate is 20 breaths/min, and his O2 saturation is 95% while breathing room air. The patient is not in acute distress. The head, eyes, ears, nose, and throat (HEENT) examination shows well-healing facial lacerations with intact sutures. His chest is clear to auscultation on both sides, with normal cardiovascular and abdominal findings. The lower extremities have normal sensation and 5/5 strength
A visible fluid collection is observed in the proximal lateral aspect of his right thigh. The fluid seems to track up around the gluteus maximus muscle to the lumbosacral region, with slight crossing of the midline to the left (see patient photograph). The fluid appears to be a free-flowing, low-viscosity collection without evidence of erythema or ecchymosis. No loculation is noted on palpation, and the patient has no thickening or induration of the skin in the overlying and surrounding areas.
UA: 0-5 WBC, 5rbc, no bacteria, no nitrites, small blood, small protein, normal specific gravity
CBC: hgb 12, hct 35, wbc 10, platelets 230
bmp: na 135, k 4, cl 105, co2 25, BUN 18, cr 1.1, glucose 110
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