From the Guidelines
To chart physical findings for cellulitis of the right middle finger, document the specific location as "right middle finger" and describe all observable characteristics including erythema, edema, warmth, tenderness, any drainage or discharge, and the precise boundaries of the infection. When documenting physical findings, it is essential to note the presence or absence of red streaking (lymphangitis), lymphadenopathy in the axilla or epitrochlear region, and any limitation in range of motion 1. Include vital signs, particularly temperature, to assess for systemic involvement, as recommended by the practice guidelines for the diagnosis and management of skin and soft tissue infections 1. Measure and record the dimensions of the affected area in centimeters to establish a baseline for monitoring progression or improvement. Document any pain using a standardized scale (0-10) and note functional limitations. This detailed documentation is essential for establishing a baseline, monitoring treatment response, communicating with other healthcare providers, and providing medicolegal protection. Proper documentation also helps differentiate cellulitis from other conditions like gout, contact dermatitis, or deep space infections that may present similarly. Some key points to consider when charting physical findings include:
- The specific location and description of the infection
- The presence or absence of systemic signs of infection, such as fever or lymphadenopathy
- The dimensions of the affected area and any changes over time
- The patient's pain level and functional limitations
- Any potential complications or comorbidities, such as immunocompromised status or underlying cutaneous disorders 1. By following these guidelines and documenting physical findings thoroughly, healthcare providers can ensure that patients receive appropriate treatment and care for cellulitis of the right middle finger.
From the Research
Charting Physical Findings for Cellulitis
To chart physical findings for cellulitis of the right middle finger, consider the following:
- Location: Right middle finger
- Characteristics:
- Erythema (redness)
- Warmth
- Swelling
- Tenderness
- Pain (as reported by the patient)
- Distribution and extent of the affected area: Document the size and shape of the affected area, including any areas of increased redness, warmth, or swelling.
- Presence of any discharge, pus, or other abnormal findings: Note any unusual odors, discharge, or other signs of infection.
Assessment and Documentation
When assessing and documenting physical findings for cellulitis, consider the following:
- Use a standardized method for documenting physical findings, such as a body map or diagram.
- Include measurements of the affected area, if possible.
- Document any changes in the patient's condition over time, including response to treatment. As noted in studies 2, 3, 4, 5, 6, cellulitis is a clinical diagnosis based on history and physical examination, and lacks a gold standard for diagnosis.
Key Findings to Document
Key findings to document when charting physical findings for cellulitis include:
- Onset and duration of symptoms
- Severity of symptoms (e.g. mild, moderate, severe)
- Presence of any underlying medical conditions or risk factors (e.g. prior episodes of cellulitis, cutaneous lesions, tinea pedis, chronic edema)
- Response to treatment, including any changes in symptoms or physical findings over time. Studies 2, 3, 4, 5, 6 emphasize the importance of thorough history and clinical examination in diagnosing and managing cellulitis.