DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has suffered from a wound at the posterior aspect of the right Achilles tendon for approximately three years. She has received care with a variety of wound healing modalities, including Hydrofera Blue, Santyl collagenase, and most recently gentamicin cream. Currently, she receives dressing changes using Prisma. She has received compression associated with the dressing changes in the form of Coban 1 in the past, but this was recently discontinued. She has also been immobilized in a Cam walker but notes that the device caused a hematoma on the affected limb and was hence discontinued recently also. She presents today for further evaluation of the wound.
PAST MEDICAL HISTORY: Hypertension, CVA, chronic pain syndrome, fibromyalgia, rheumatoid arthritis, systemic lupus erythematosus, peripheral neuropathy, osteoarthritis, DVT, PE, insomnia, venous insufficiency of the lower limbs, depression, anxiety, and gastroesophageal reflux disease.
PAST SURGICAL HISTORY: Two Achilles tendon repairs of the right lower extremity.
SOCIAL HISTORY: The patient does not use tobacco or alcohol products. She does not use illicit or recreational drugs.
ALLERGIES: Multiple medication allergies, listed in the chart.
MEDICATIONS: Cardizem, Aggrenox, Norflex, Neurontin, Plaquenil, diclofenac, Coumadin, Ambien, sucralfate, prednisone, and Lortab.
REVIEW OF SYSTEMS: She denies nausea, fever, vomiting or chills. She has no chest pain, shortness of breath or palpitations. She denies rest pain, intermittent claudication or calf tenderness.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 98.2, pulse 70, respirations 18, and blood pressure 154/78.
EXTREMITIES: A full-thickness ulceration is noted at the posterior aspect of the right Achilles tendon. The wound extends onto the level of the tendon, which is exposed in the ulceration medially. The wound base is mostly fibrotic, although a few red granulation buds are noted along the lateral expansion of the lesion. The epithelial margins are viable overall associated with mild hyperkeratosis. The wound produces moderate serous exudate without associated purulence or malodor. There is no erythema or increase in temperature or any other clinical signs of infection. Pitting edema does consume the entire right lower limb from the level below the knee to the level of the ankle. Wound cultures obtained from the site produced light growth of Staphylococcus aureus. The patient was treated with gentamicin cream at that time for one week before she was converted to Prisma.
ASSESSMENT:
1. Chronic right Achilles tendon ulceration.
2. Chronic venous hypertension of the right lower extremity.
3. Multiple comorbidities that will deter wound healing, including rheumatoid arthritis and systemic lupus erythematosus.
PLAN: We will continue the current wound protocol. See operative report for details regarding debridement of the wound. We have advised the patient that compression therapy is essential in order to achieve wound healing. We will employ a foam pad over the ulceration to prevent excessive pressure and reinitiate use of the Coban 1 bandage to decrease the edema in the affected limb.
We will attempt to arrange for a new Cam walker for the patient as immobilization of the Achilles tendon is also essential to achieve wound healing. We will make certain that the new device does not cause any further irritation. Future considerations for wound healing therapy would be Santyl collagenase under saline-moistened Hydrofera Blue or Regranex.
