[##]-year-old [male/female] with history and exam consistent with
abscess to the [location].
Initial consideration in this patient included abscess, cellulitis,
cyst, necrotizing fasciitis, and other deep space infections among others.
Patient presented with complaint of [boil/swelling/redness], and was noted
to have [fluctuant mass palpable on exam/bedside ultrasound evidence]
consistent with abscess. Abscess felt to
be amenable to incision and drainage (I&D) based on size on duration of
symptoms. After discussion of risks,
benefits, and alternatives to I&D, the patient provided [verbal/written]
consent to the procedure as noted above.
The abscess cavity was evacuated and probed thoroughly without evidence
of significant depth or extension. The
abscess cavity [was/was not] packed [due to small size of the cavity after
drainage]. The patient tolerated the
procedure well without significant complications as noted above.
Antibiotic treatment was felt [to be indicated based on the size of the
abscess and the patient’s comorbid conditions/to not be indicated at this time
based on appropriate drainage and packing of the patient’s abscess]. Prior to discharge, we discussed return
precautions, treatment, and follow up with primary care doctor within one week
for further evaluation, and the patient demonstrated understanding and
agreement with this plan.
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