Rajapandi
New
Hi, When patient came for recurrent pilonidal cyst (symptom-pain) or recurrent UTI (symptom-pain, dysura) or recurrent sinusitis (facial pressure, post nasal drip) with related symptoms, Can we consider this acute complicated illness? generally those are go with acute uncomplicated illness. I stuck with the word recurrent. Kindly clarify.
Chief Complaint
As cyst on lower back he had surgery on 4 years ago, Came back two days ago and popped but didn't drain completely. Painful
History of Present Illness
The patient presents with a recurrent infected pilonidal cyst. It opened some and drained on Saturday. He had surgery 4 years ago for the same thing and it was good until 2 or 3 months ago when he had a recurrence. It opened and drained at that time. No fever. No nausea or vomiting. No systemic symptoms. No treatment has been tried. ROS all other systems negative.
Physical Examination
General: Alert and oriented, No acute distress.
Respiratory: Respirations are non-labored.
Cardiovascular: Normal rate.
Integumentary: Warm, Dry, Pink, No rash, The patient's gluteal cleft has a 1 cm inflammatory cystic structure with some mild purulent drainage. There appears to be a sinus track centrally. Tender in the local area..
Assessment
The patient has a recurrent pilonidal cyst with inflammation and infection. After patient's consent regarding the risk of bleeding infection and recurrence we cleaned the area in the normal fashion and use 11 blade scalpel to incise and drain some purulent debris and apply a 4 x 4 dressing. We will place him on Augmentin twice daily for 10 days and have him do soaks couple times a day. I like to have him see general surgery in Mason City who saw him 4 years ago and did a procedure for the same. Follow-up as needed. Prescribed amoxicillin-clavulanate 875 mg-125 mg oral tablet
Chief Complaint
As cyst on lower back he had surgery on 4 years ago, Came back two days ago and popped but didn't drain completely. Painful
History of Present Illness
The patient presents with a recurrent infected pilonidal cyst. It opened some and drained on Saturday. He had surgery 4 years ago for the same thing and it was good until 2 or 3 months ago when he had a recurrence. It opened and drained at that time. No fever. No nausea or vomiting. No systemic symptoms. No treatment has been tried. ROS all other systems negative.
Physical Examination
General: Alert and oriented, No acute distress.
Respiratory: Respirations are non-labored.
Cardiovascular: Normal rate.
Integumentary: Warm, Dry, Pink, No rash, The patient's gluteal cleft has a 1 cm inflammatory cystic structure with some mild purulent drainage. There appears to be a sinus track centrally. Tender in the local area..
Assessment
The patient has a recurrent pilonidal cyst with inflammation and infection. After patient's consent regarding the risk of bleeding infection and recurrence we cleaned the area in the normal fashion and use 11 blade scalpel to incise and drain some purulent debris and apply a 4 x 4 dressing. We will place him on Augmentin twice daily for 10 days and have him do soaks couple times a day. I like to have him see general surgery in Mason City who saw him 4 years ago and did a procedure for the same. Follow-up as needed. Prescribed amoxicillin-clavulanate 875 mg-125 mg oral tablet