Chapter 2: The Integumentary System | Matthew Dixon's Chart Note

CHART NOTE

Patient Name: Dixon, Matthew
ID Number: 98651
Examination Date: February 16, 20xx

SUBJECTIVE
Patient presents with painful lump on right side of neck. Slight fever of 101°F, but denies any chills or sweating.

OBJECTIVE
There is an erythematous cystic lesion of the epidermis measuring 3×4 cm. The mass is fluctuant (movable and compressible) and slightly tender to the touch. No lymphadenomegaly (enlarged lymph glands) noted.

ASSESSMENT
Infected sebaceous cyst; right neck.

PLAN
Area was sterilely prepped and injected with 1% lidocaine (drug that numbs). A #11 scalpel blade was used to incise the pyogenic cyst. Copious amounts of purulent (pus-containing) material and sebum were extracted. Wound was irrigated with sterile saline solution and packed with ¼-inch gauze, and sterile dressing was applied. The sebaceous material was sent for culture. Prescribed cephalexin 250 mg q.i.d. × 10 days (take a 250 mg tablet of cephalexin, an antibiotic, 4 times per day for 10 days). Will return in 2 days for recheck.