History and Physical Examination Case 8

HISTORY AND PHYSICAL EXAMINATION_______________________ Patient Name: Chapman Robert Kinsey Patient ID: 110589 Room No.: 322-B Date of Admission: 23 February ---Admitting Physician: Martha C. Eaton, MD, Geriatrics Chief Complaint: Admitted from Dr. Max Hirsch’s office due to deep ulcer on left toe. Admitting Diagnoses 1. Severe peripheral vascular disease, status post deep ulcer on left toe. Rule out thrombolysis. The patient was admitted to a regular floor. Condition is serious. 2. ALLERGY TO PENICILLIN, which puts patient into anaphylactic shock. 3. Continue with home medications. DETAILS OF PRESENT ILLNESS: Mr. Kinsey is an 87-year-old white gentleman with history of (1) Chronic atrial fibrillation, on Coumadin. (2) Chronic deafness, bilateral. (3) Severe peripheral vascular disease. (4) Status post left endarterectomy done in November of last year. (5) Chronic renal failure. (6) Status post right great toe amputation secondary to peripheral vascular disease. (7) Status post cataract surgery. (8) CHF; class 1. (9) Incontinence of stool. The patient was seen by Gary Shelton, DPM, on 18 February with a history of 3 weeks’ ulcer on the toe. Podiatrist referred the patient to Tomas Burgos, Vascular Surgery, who suggested that the patient should have an arteriogram. The patient also saw Dr. Hirsch today because of the ulcer on his toe. Dr. Hirsch’s decision was that the patient should be admitted to the hospital for incision and drainage of the ulcer as well as IV antibiotics. As an outpatient, the patient had x-ray at the provider DPM's office. Also, the patient had bone scan done on 18 February, which was reported as increased uptake in the mid aspect of the left 1st metatarsal, right metatarsal head, and the 3rd phalanx, cannot rule out osteomyelitis. (Continued) DOB: 7/4/---Age: 87 Sex: Male

HISTORY AND PHYSICAL EXAMINATION Patient Name: Chapman Robert Kinsey Patient ID: 110589 Date of Admission: 23 February ---Page 2

MEDICATIONS: Warfarin or Coumadin,