[##]-year-old [breastfeeding] female with [redness/irritation/swelling]
of the [right/left/bilateral] breast(s) with history and exam consistent with
likely mastitis.
Initial considerations in this patient included mastitis, cellulitis,
mechanical irritation of the breast, systemic infectious processes, and
necrotizing soft tissue infections among others.
Patient presented with [erythema/swelling/tenderness] of the
[right/left/bilateral] breast with associated [fever/chills/flu-like symptoms]
concerning for mastitis [in the setting of breastfeeding]. Labs [were/were not] obtained in the
evaluation of this patient [based on absence of response to antibiotics after 2
days, recurrent episode of mastitis, hospital acquired mastitis, reported
allergy to standard antibiotic therapy, or severe or unusual case/absence of
concerning features]. [Labs were noted
to be unremarkable/notable for specify.]
A [bedside/formal] ultrasound was obtained with [no evidence of concurrent
abscess/evidence of superficial/deep abscess measuring ## cm]. [Given superficial/deep nature of abscess, a
needle aspiration was performed under ultrasound guidance/surgery was consulted
for further management.]
[The site of cellulitis was marked prior to discharge from the ED
with strict return precautions given for evidence of worsening infection.] We discussed return precautions, specifically
for evidence of worsening infection, treatment with [Dicloxacillin/Cephalexin/Clindamycin/Augmentin]
and symptomatic treatment, and follow up with primary care doctor within 2-3
days for further evaluation of response to therapy, and the patient
demonstrated understanding and agreement.
Prior to discharge, we emphasized the importance of continuing to breastfeed
while on antibiotics, and the patient demonstrated understanding and agreement
with this recommendation.
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