Gerald Edwards Discharge Summary
HILLCREST MEDICAL CENTER
DISCHARGE SUMMARY
Patient Name: Gerald Edwards
Hospital No.: 11058
Date of Admission: 07/15/2010
Date of Discharge: 07/20/2010
Consultations: Gary Shelton, DPM and Midori Okano, MD
Procedures: Complicated incision and drainage, right foot, on 07/17/2010.
Complications: None
Admitting Diagnosis: Known diabetes mellitus. Ulceration of right foot.
HISTORY: The patient is a 53-year-old black individual, who has had diabetes for at least six months, but thinks it has been longer than that. He has had a foot ulcer since January.
Physical exam at the time of admission is significant for his lower extremities where he had good dorsalis and posterior tibial pulses bilaterally. His …show more content…
left foot had no abrasions, lesions, sores or ulcers. His right foot showed obvious deformity from a previous break. He has an area located between his second and third metatarsal head that has clearly been an abscess that has broken through. He also has had a foot ulcer located on the instep of his right foot, full thickness. There is tracking to the broken foot ulcerated area and there is question of osteomyelitis in this area.
DIAGNOSTIC EXAMINATION: During this hospital stay white blood count was initially 16,800 then 12, 000 one day post op. H&H were normal. UA was essentially unremarkable. Electrolytes were fairly normal with a glycosylated hemoglobin of 8.6 measured. Thyroid panel was normal. Urine chemistries revealed a protein of 0.18, a microalbumin of 44, and a creatinine of 0.69. Creatinine clearance was estimated at 31.8 and sed rate was 79. Blood cultures were negative. Swabs of the abscessed area revealed many beta streptococci. X-rays revealed heart size normal, lung fields clear. Right foot showed no acute changes other than moderate soft tissue swelling around the right toe. Left foot revealed no acute bony abnormalities. An MRI of the feet revealed marked soft tissue abnormalities of the right foot with plantar ulcer area of the first metatarsophalangeal joint, highly suggested of rampant cellulitis. Definite osteomyelitis could not be defined on this study.
(Continued)
DISHCHARGE SUMMARY
Patient Name: Gerald Edwards
Hospital No.: 11058
Date of Discharge: 07/20/2010
Page 2
HOSPITAL COURSE: The patient was admitted and the above laboratory examinations were obtained.
The patient was placed initially on a sliding scale of insulin. The patient underwent incision and drainage of his right foot on July 17, had no complications and tolerated surgery well. One day post-op the patient spiked a temperature to 101 degrees Fahrenheit. The patient was placed on Unasyn. He defervesced quickly. At the time of discharge his vital signs were stable. He was afebrile. His antibiotics were changed to Augmentin and he was discharged to his daughter’s home.
DISPOISTION: The patient was discharged three days post-op in good condition on Augmentin 500 mg p.o.q. 8h. And insulin on a sliding scale.
FOLLOW UP: The patient is to be followed by Dr. Shelton in his office, first available appointment and by Dr. Okano’s office in six months. To call his doctor or come back to Hillcrest ER for any signs of wound infection, fever, pain or bleeding.
DISCHARGE DIAGNOSES
1. Diabetes mellitus, insulin dependent.
2. Diabetic neuropathy.
3. Chronic ulcer of the right
foot.
4. Cellulitis of the right foot.
5. Background diabetic retinopathy.
6. Charcot disease.
7. Incision and drainage wound of right foot.
_________________________
Catherine Baker, MD
Cb
D:07/21/2010
T:02/04/2010
DISCHARGE SUMMARY
Patient Name: Gerald Edwards
Hospital No.: 11058
Date of Admission: 07/15/2010
Date of Discharge: 07/20/2010
Consultations: Gary Shelton, DPM and Midori Okano, MD
Procedures: Complicated incision and drainage, right foot, on 07/17/2010.
Complications: None
Admitting Diagnosis: Known diabetes mellitus. Ulceration of right foot.
HISTORY: The patient is a 53-year-old black individual, who has had diabetes for at least six months, but thinks it has been longer than that. He has had a foot ulcer since January.
Physical exam at the time of admission is significant for his lower extremities where he had good dorsalis and posterior tibial pulses bilaterally. His …show more content…
left foot had no abrasions, lesions, sores or ulcers. His right foot showed obvious deformity from a previous break. He has an area located between his second and third metatarsal head that has clearly been an abscess that has broken through. He also has had a foot ulcer located on the instep of his right foot, full thickness. There is tracking to the broken foot ulcerated area and there is question of osteomyelitis in this area.
DIAGNOSTIC EXAMINATION: During this hospital stay white blood count was initially 16,800 then 12, 000 one day post op. H&H were normal. UA was essentially unremarkable. Electrolytes were fairly normal with a glycosylated hemoglobin of 8.6 measured. Thyroid panel was normal. Urine chemistries revealed a protein of 0.18, a microalbumin of 44, and a creatinine of 0.69. Creatinine clearance was estimated at 31.8 and sed rate was 79. Blood cultures were negative. Swabs of the abscessed area revealed many beta streptococci. X-rays revealed heart size normal, lung fields clear. Right foot showed no acute changes other than moderate soft tissue swelling around the right toe. Left foot revealed no acute bony abnormalities. An MRI of the feet revealed marked soft tissue abnormalities of the right foot with plantar ulcer area of the first metatarsophalangeal joint, highly suggested of rampant cellulitis. Definite osteomyelitis could not be defined on this study.
(Continued)
DISHCHARGE SUMMARY
Patient Name: Gerald Edwards
Hospital No.: 11058
Date of Discharge: 07/20/2010
Page 2
HOSPITAL COURSE: The patient was admitted and the above laboratory examinations were obtained.
The patient was placed initially on a sliding scale of insulin. The patient underwent incision and drainage of his right foot on July 17, had no complications and tolerated surgery well. One day post-op the patient spiked a temperature to 101 degrees Fahrenheit. The patient was placed on Unasyn. He defervesced quickly. At the time of discharge his vital signs were stable. He was afebrile. His antibiotics were changed to Augmentin and he was discharged to his daughter’s home.
DISPOISTION: The patient was discharged three days post-op in good condition on Augmentin 500 mg p.o.q. 8h. And insulin on a sliding scale.
FOLLOW UP: The patient is to be followed by Dr. Shelton in his office, first available appointment and by Dr. Okano’s office in six months. To call his doctor or come back to Hillcrest ER for any signs of wound infection, fever, pain or bleeding.
DISCHARGE DIAGNOSES
1. Diabetes mellitus, insulin dependent.
2. Diabetic neuropathy.
3. Chronic ulcer of the right
foot.
4. Cellulitis of the right foot.
5. Background diabetic retinopathy.
6. Charcot disease.
7. Incision and drainage wound of right foot.
_________________________
Catherine Baker, MD
Cb
D:07/21/2010
T:02/04/2010