SUBJECTIVE: The patient is a (XX)-year-old Hispanic male who is followed here in the Wound Center for marked edema of both of his lower extremities with ulcerations present as a result of this edema. He has end-stage renal disease secondary to his diabetes and gets dialysis three times a week, which does help with his edema. He was measured for Jobst stockings and has those that he keeps in place and they have been a help for his edema. He feels like his pain is better using his compression stockings. He is trying to elevate his extremities when he is sitting down to help with his edema. He does say that he is trying to take in good nutrition to help heal these wounds.
He was seen on Monday by Dr. John Doe at the Vascular Center regarding the wounds of his lower extremity to evaluate him for the report of greater than or equal to 50% stenosis of his right posterior tibial artery as well as to assess him for potential for closure procedure for this marked edema that he experiences. Dr. John Doe said that they were in agreement that the probable cause of his lower extremity ulcers is venous insufficiency, which they believe to be stage VI. Their recommendation was to continue with the compression stockings. Their plan will be to follow him up in two months at which time they will repeat a venous reflux study to see if there is a possibility of intervention that may be helpful to him.
OBJECTIVE: VITAL SIGNS: Temperature is 36.6, pulse is 86, respiratory rate is 20, and blood pressure is 134/52. GENERAL: The patient is an obese Hispanic male who is in no acute distress. He is alert. He is cooperative. He is pleasant in nature. EXTREMITIES: Examination of his ulcers reveals ulcer #1 to be located in the right medial distal portion of his lower leg. It measures 1.3 x 1.3 x 0.2. There is no sinus tract, no tunneling or undermining associated with that wound. There is only a very small amount of serous drainage coming from the wound. He has a small amount of granulation tissue in the wound base with a large amount of yellow fibrinous slough in that wound. The wound has experienced a small amount of epithelialization since we saw him last week. There is no evidence of infection as there is no odor, no erythema, no abnormal discharge coming from the wound.
Ulcer #2 is of the right medial lower extremity just above ulcer #1. It measures 1.0 x 1.0 x 0.2. There is no sinus tract, no tunneling, no undermining associated with it. There is only a small amount of serous exudate coming from the wound. There is no ability to appreciate any granulation tissue in the wound base. It is completely covered with a yellow fibrinous slough. There is no epithelialization occurring with that wound. There is no evidence of any infection as there is no erythema, no odor, no abnormal discharge coming from the wound.
Ulcer #3 is of left lateral leg. It measures 1.1 x 0.9 x 0.3. There is no sinus tract, no tunneling and no undermining associated with it. There is a small amount of serous drainage coming from it. There is no ability to appreciate any granulation tissue in the wound base as there is a large amount of yellow fibrinous slough overlying the whole wound base obscuring any good granulation tissue. There may be minimal epithelialization to this wound. There is no evidence of infection as there is no erythema, no odor, no abnormal discharge coming from the wound.
PROCEDURES PERFORMED: The operative procedure today is an excisional debridement on ulcer #1. Ulcer #1 is located in the right medial distal extremity. Its pre-debridement measurement is 1.3 x 1.3 x 0.2. Its post-debridement measurement is 1.3 x 1.3 x 0.3. The appearance of the wound shows that there is a large amount of yellow fibrinous slough overlying some healthy granulation tissue. We have taken a 4 mm curette and curetted away all of this yellow fibrinous debris until we get down to some nice, healthy granulation tissue in the subcutaneous tissue space. The wound was anesthetized with 1% lidocaine injected into the wound area as well as some topical Hurricaine spray. The bleeding was controlled with simple pressure to the wound. The wound was covered with a Prisma dressing with his Jobst stocking put back into place. The patient tolerated the procedure well.
The next procedure is on ulcer #2. It is an excisional debridement. The location of the wound is the right medial extremity just proximal to ulcer #1. Its pre-debridement measurement is 1.0 x 1.0 x 0.2. Its post-debridement measurement is 1.0 x 1.0 x 0.3. The appearance of the wound shows a large amount of yellow fibrinous slough in the wound base obscuring any healthy granulation tissue at all. We have taken a 4 mm curette and curetted away this yellow fibrinous slough until we got down to nice, healthy granulation tissue in the subcutaneous tissue level. Bleeding was controlled with simple pressure to the wound. The wound was anesthetized with lidocaine 1% injected into the wound with Hurricaine spray put topically over the wound. Prisma was placed into the wound with the Jobst stockings put back in place. The patient tolerated the procedure well without any difficulties.
The next procedure is on ulcer #3. Ulcer #3 is located in the left lateral leg. It is an excisional debridement. The pre-debridement measurement is 1.1 x 0.9 x 0.3. The post-debridement measurement is 1.1 x 0.9 x 0.4. The appearance of the wound shows a large amount of yellow fibrinous necrotic material overlying the wound base so that there is no ability to appreciate any granulation tissue in that wound base. We have taken a 4 mm curette and curetted away this yellow fibrinous necrotic material until we got down to some nice, healthy granulation tissue in the subcutaneous tissue level. Bleeding was controlled with simple pressure to the wound. We have used lidocaine 1% injected into the wound as well as topical Hurricaine spray for anesthesia. Prisma was placed into the wound with his Jobst stockings put in place over that. The patient tolerated the procedure well.
ASSESSMENT AND PLAN: The patient has marked edema of his bilateral lower extremities with the vascular surgeons giving him a diagnosis of venous insufficiency, which they believe to be stage VI. Their plan is to follow him up in two months at which time they will repeat a venous duplex study to see if there is a possibility of intervention that may be helpful for his symptoms. In the meantime, we are going to continue compression with his Jobst stockings. We have asked him to elevate his extremities when he is sitting down. He is trying to take in good nutrition to help heal these wounds. He is to try and keep his diabetes under control for helping with wound healing. We will plan on seeing him back here in one week for further evaluation and treatment of his venous insufficiency disease.
