DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female patient whom we have followed in the wound care center due to left lower extremity ulceration. The patient did have a lot of pain in her lower extremities. There was much increase in erythema and the wounds did look deeper.
She is scheduled apparently for angiography of her legs. However, due to the pain and apparent cellulitis, we have directly admitted her.
REVIEW OF SYSTEMS: Unless stated above, all 10 systems were reviewed in detail with the patient and negative unless stated above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Refer to the chart.
GENERAL: The patient is in no acute distress. She is awake and oriented x3.
HEENT: Oropharynx is clear. Moist mucous membranes. No JVD, LAD or thyromegaly.
HEART: Regular rate and rhythm. Normal S1, S2. No S3 or S4. No murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes or crackles.
ABDOMEN: Bowel sounds are present. Soft, nontender, and nondistended. There is no hepatosplenomegaly.
EXTREMITIES: No clubbing or cyanosis, 1+ bilateral lower extremity edema. The left lower extremity has extensive ulcerations on her left calf, left dorsum of her foot, and left shin.
LABORATORY DATA: Labs at this time have been ordered.
ASSESSMENT AND PLAN: We discussed with the patient’s primary care, who is attending the need for angiography for left lower extremity. For now, infectious disease has been consulted for intravenous antibiotics, and we do believe there is an underlying infection.
Locally, for wound care, we would use Iodosorb along with silver alginate to be applied to the left lower extremity ulceration. We will cover this with 4 x 4, wrapped in Kerlix to be changed daily.
The patient’s buttock does have ulcerations as well. We have ordered a stage IV mattress. Calmoseptine is to be used liberally q. 8 hours and as needed. We will follow along for wound care closely.
