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Present complains : infection on the leg

First of date complains : 11/11/2020

Patient complains :

Patient complains of having infection on his right leg since 3 days ago after got bump into the fin when
he was surfing. He feels a bit pain of it. He already took the amoxicillin 3 days ago in Banda. There is no
any other symptoms reported.

General condition :

Compos mentis

On examination :

Vital sign within normal limit

Localis state e.r cruris d :

L : vulnus excoriatum (+), crusta (+), hyperemic (+), minimal swelling (+)

F : minimal pain on palpation (+)

M : ROM not limited

Lab result :

Not done

Diagnose :

Vulnus excoriatum with secondary infection

Treatment :

Medication and advice

Medication :

Prescription :

Cefacef 100mg bid 1 cap for 5 days

Doctor recommend :

Elevate the leg

Take the medicines as doctor instruction


If the symptoms persist/getting worse suggestion to meet doctor

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