DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Great toe ulcer.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with a history of diabetes and neuropathy who presents today with a left great toe ulcer. He has had an infection there since February. He has been on Keflex. He saw the podiatrist today who recommended coming to the emergency department for admission and possible surgical amputation. The patient denies fevers, chills or sweats. His blood sugar today was 94 and otherwise has been feeling well. He has had no other problems with infections of the lower extremities.
PAST MEDICAL HISTORY: Diabetes, depression, hypertension, urinary urgency, sleep apnea, diabetic neuropathy, and chronic back pain.
PAST SURGICAL HISTORY: Right knee replacement.
ALLERGIES: None.
MEDICATIONS: Glyburide, metformin, fluoxetine, Lotrel, vitamin C, iron, Byetta, a bladder medication, and other medications he is unclear of.
SOCIAL HISTORY: The patient drinks one beer a day. He denies tobacco and drug use.
REVIEW OF SYSTEMS: The patient is a (XX)-year-old presenting with great toe infection. See HPI for review of systems. All other systems negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 152/78, pulse 90, respirations 20, pulse ox 98% on room air, and temperature 98.6.
GENERAL: Otherwise healthy, well-developed, well-nourished (XX)-year-old male who is alert and oriented x3, nontoxic, in no apparent distress.
EXTREMITIES: On examination of the right toe, the patient does have some swelling and some area of purulence. No significant abscess. It is nontender to palpation. There is no lymphangitic streaking or evidence of infection spreading to the dorsum of the foot. His pulses are +2. His sensation is decreased secondary to his neuropathy. He is able to ambulate.
EMERGENCY DEPARTMENT COURSE: The patient was seen and evaluated by Dr. Jane Doe who agrees with the assessment and plan. The patient had an x-ray that revealed bony destruction of the distal tuft of the toe and base of the distal phalanx consistent with osteomyelitis. There is also osteoarthritis at the first MTP joint. The patient had a sedimentation rate, CBC, and renal. He was evaluated by the podiatry resident. The plan was to admit the patient; however, he had to pick up his son from school today. There was no other person that could do it, and he has agreed to come back tomorrow for direct admission to the podiatry service.
MEDICAL DECISION MAKING: The patient is a (XX)-year-old presenting with toe infection. At this time, he has osteomyelitis of his left great toe, which will be repaired by Podiatry. He will be a direct admit tomorrow to their service and at this time was discharged home. He has had his labs drawn and will be seen tomorrow by Podiatry. Declined any antibiotics at this time.
ASSESSMENT: Osteomyelitis of the left great toe.
PLAN: The patient has returned home. Return tomorrow for admission and sooner for nausea, vomiting, fevers, chills, sweats or any other problems.
