Consult - History and Phy.
Sample Name: Insect Sting
Description: Local reaction secondary to insect sting. Patient was stung by a bee on his right hand, left hand, and right knee at approximately noon today.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: Patient is a 76-year-old white male who presents with his wife stating that he was stung by a bee on his right hand, left hand, and right knee at approximately noon today. He did not note any immediate reaction. Since that time, he has noted some increasing redness and swelling to his left hand, but he denies any generalized symptoms such as itching, hives, or shortness of breath. He denies any sensation of tongue swelling or difficulty swallowing.
The patient states he was stung approximately one month ago without any serious reaction. He did windup taking Benadryl at that time. He has not taken anything today for his symptoms, but he is on hydrochlorothiazide and metoprolol for hypertension as well as a baby aspirin each day.
ALLERGIES: HE DOES HAVE MEDICATION INTOLERANCES TO SULFA DRUGS (HEADACHE), MORPHINE (NAUSEA AND VOMITING), AND TORADOL (ULCER).
SOCIAL HISTORY: Patient is married and is a nonsmoker and lives with his wife, who is here with him.
Nursing notes were reviewed with which I agree.
VITAL SIGNS: Temp and vital signs are all within normal limits.
GENERAL: In general, the patient is an elderly white male who is sitting on the stretcher in no acute distress.
HEENT: Head is normocephalic and atraumatic. The face shows no edema. The tongue is not swollen and the airway is widely patent.
NECK: No stridor.
HEART: Regular rate and rhythm without murmurs, rubs, or gallops.
LUNGS: Clear without rales, rhonchi, or wheezes.
EXTREMITIES: Upper extremities, there is some edema and erythema to the dorsum of the left hand in the region of the distal third to fifth metacarpals. There was some slight edema of the fourth digit, on which he still is wearing his wedding band. The right hand shows no reaction. The right knee is not swollen either.
The left fourth digit was wrapped in a rubber tourniquet to express the edema and using some Surgilube, I was able to remove his wedding band without any difficulty. Patient was given Claritin 10 mg orally for what appears to be a simple local reaction to an insect sting. I did explain to him that his swelling and redness may progress over the next few days.
ASSESSMENT: Local reaction secondary to insect sting.
PLAN: The patient was reassured that this is not a serious reaction to an insect sting and he should not progress to such a reaction. I did urge him to use Claritin 10 mg once daily until the redness and swelling has gone. I did explain that the swelling may worsen over the next two to three days, it may produce a large local reaction, but that anti-histamines were still the mainstay of therapy for such a reaction. If he is not improved in the next four days, follow up with his PCP for a re-exam.
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