Lower Extremity Cellulitis Sample Report
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Lower extremity cellulitis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old moderately obese male with a history of recurrent cellulitis of the lower extremity. He has chronic lymphedema. The patient says the problem started after he had a coronary bypass surgery when the vein was harvested from the leg. Recently, he started having increasing redness on both legs, about three weeks ago, and progressively got worse and hence came to the hospital. The patient denies any fever or chills.
PAST MEDICAL HISTORY: Significant for coronary artery disease, history of colon cancer, chronic lymphedema, hypertension, obesity, and hyperlipidemia.
PAST SURGICAL HISTORY: Partial colectomy and has colostomy, coronary bypass surgery.
ALLERGIES: PENICILLIN.
MEDICATIONS: The patient is on IV clindamycin.
SOCIAL HISTORY: The patient denies smoking. Drinks about 2-3 beers every week. He lives with his daughter.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As per HPI, otherwise negative. The patient has had cough with whitish, frothy sputum.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8 degrees, pulse 54, respirations 18, and blood pressure 154/86.
HEENT: Unremarkable.
NECK: No lymphadenopathy.
LUNGS: Expiratory rhonchi bilaterally.
HEART: S1 and S2. Regular rhythm.
ABDOMEN: Nontender. Bowel sounds present.
EXTREMITIES: Bilateral lower extremity with erythema and edema along with some blisters on both legs.
NEUROLOGIC: No focal neurological deficits.
LABORATORY DATA: White count 8.4, hemoglobin 11.8, platelets 276. BUN and creatinine 10.2 and 1. Glucose 92. Wound, left ankle area, 2+ gram-positive cocci on Gram stain.
DIAGNOSTIC DATA: Chest x-ray shows bilateral effusions and interstitial edema.
IMPRESSION:
1. Bilateral lower extremity cellulitis, recurrent, because of chronic lymphedema.
2. Congestive heart failure, history of coronary artery disease.
RECOMMENDATIONS:
1. Continue clindamycin. Would increase dose to 900 mg IV q. 8 hours.
2. Consider diuresis.
3. We will get lymphedema consult.
4. Check BMP.
Thank you, Dr. Doe, for the opportunity to participate in this patient’s care.
