SOAP Note
Subjective:
The patient is a 47-year-old male presenting with a complaint of a bug bite next to his left ear that occurred 3 days ago. He reports that the area has become increasingly swollen over the past 2 days. Additionally, he mentions developing a scratchy throat since this morning.
Objective:
- CBC shows monocytes absolutely 1.1, which is slightly elevated, but otherwise unremarkable.
- CMP reveals a creatinine level of 0.70 and an ALT (SGPT) of 59, which is mildly elevated, but otherwise unremarkable.
- CT maxillofacial scan indicates mild peri-orbital edema, suggesting an inflammatory process, with no evidence of abscess, well-aerated sinuses, and no fracture.
Assessment:
The patient's presentation suggests an inflammatory process, possibly related to the bug bite, with systemic symptoms such as a scratchy throat and mild laboratory abnormalities.
Plan:
Given the differential diagnoses below, the plan would involve further diagnostic workup, potential antibiotic treatment, and close monitoring for signs of worsening infection or other complications.
Differential Diagnoses
- Single Most Likely Diagnosis
- Cellulitis: Given the history of a bug bite followed by increasing swelling and the presence of mild peri-orbital edema on the CT scan, cellulitis is a likely diagnosis. The scratchy throat could be an unrelated viral pharyngitis or an early sign of a more systemic infection.
- Other Likely Diagnoses
- Insect Bite Reaction: An exaggerated response to the insect bite could explain the local swelling and systemic symptoms like a scratchy throat.
- Viral Pharyngitis: The scratchy throat could be due to a viral infection, which might be coincidental but should be considered, especially with the mild elevation in monocytes.
- Do Not Miss (Deadly if Missed)
- Ludwig's Angina: Although the CT scan does not show an abscess, Ludwig's angina is a life-threatening condition that requires prompt recognition and treatment. The presence of swelling and a scratchy throat could be early signs.
- Orbital Cellulitis: The peri-orbital edema noted on the CT scan could be an early sign of orbital cellulitis, which is a serious infection requiring immediate antibiotic treatment.
- Rare Diagnoses
- Erythema Migrans (Lyme Disease): If the bug bite was from a tick, Lyme disease could be a consideration, although the presentation would be atypical without the characteristic rash.
- Cat-Scratch Disease: If the "bug bite" was actually from a cat scratch, this could be a possibility, especially with the lymphocytic response (elevated monocytes) and local swelling.