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 has developed a scratchy throat since the morning of presentation. He denies fever, chills, shortness of breath (SOB), and fatigue.
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 some systemic signs 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 peri-orbital edema on CT scan, cellulitis is a likely diagnosis. The absence of fever and other systemic symptoms does not rule out cellulitis, as it can present with varying degrees of severity.
- Other Likely Diagnoses
- Insect Bite Reaction: An exaggerated response to the insect bite could explain the swelling and the development of a scratchy throat, possibly due to an allergic reaction.
- Periorbital Cellulitis: Although the CT scan does not show an abscess, periorbital cellulitis could be considered given the location of the swelling and the presence of peri-orbital edema.
- Do Not Miss Diagnoses
- Lyme Disease: Although less common, given the bug bite, Lyme disease should be considered, especially if the patient has been in an area where ticks are prevalent. The scratchy throat could be an early sign of the disease.
- Necrotizing Fasciitis: This is a severe infection that requires prompt recognition and treatment. Although the patient does not have the typical signs of severe pain or crepitus, the increasing swelling and the presence of an inflammatory process on CT scan warrant consideration of this diagnosis.
- Rare Diagnoses
- Erythema Migrans: A rash associated with Lyme disease, which could be considered if the patient's symptoms and the bug bite are related to a tick bite.
- Angioedema: An allergic reaction that could cause swelling, especially if the patient has a history of allergies. However, the absence of other typical symptoms such as urticaria or significant respiratory distress makes this less likely.