Answered: 4. How many ulcers did the patient have…

Phlebotomy Essentials

6th Edition

ISBN:9781451194524

Author:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Publisher:Ruth McCall, Cathee M. Tankersley MT(ASCP)

Chapter1: Phlebotomy: Past And Present And The Healthcare Setting

Section: Chapter Questions

Problem 1SRQ

See similar textbooks

Related questions

Question

4. How many ulcers did the patient have and what were the size and locations of the ulcers? 5. What type of dressings was the patient treated with? 6. If the patient's wounds do not heal within the next 2-3 weeks, what will be the next procedure the physician will perform?

Transcribed Image Text:--- ### Discharge Summary #### Patient Information - **Name:** John Doe - **Medical Record Number:** 5554411 - **Admit Date:** 10/15/85 - **Discharge Date:** 10/18/85 #### Admitting Diagnosis 1. **Bilateral, medial perimalleolar ulcer secondary to trauma** 2. **Insulin-dependent diabetes mellitus** #### History of Present Illness John Doe is a 70-year-old white male who sustained trauma to the medial malleoli approximately two weeks prior to admission while riding an all-terrain vehicle. At that time, he sustained what appeared to be minor injuries, but out-patient treatment failed to reverse the injuries. The patient subsequently lost full thickness tissues in the infra and posterior medial malleolar areas. He was evaluated and admitted to St. Joseph’s Hospital for wound care. #### Past Medical History - **Positives:** - Insulin-dependent diabetes mellitus - **Negatives:** - **Allergies:** None known - **Smoking:** No known history of cigarette smoking, although he is a pipe smoker - **Cardiac Risk:** No known history of previous cardiac risk - **Surgeries:** Appendectomy and tonsillectomy - **Foot Ulcer:** In September 1984, the patient had a foot ulcer treated non-surgically at St. Joseph’s Hospital #### Review of Systems - **Negative.** #### Physical Exam - **Vital Signs:** Temperature – 98°F; Pulse – 80 and regular; Respirations – 24; Blood Pressure – 120/76 - **Head and Neck:** Normal - **Chest:** Clear - **Heart:** Regular rate and rhythm - **Abdomen:** Normal The patient had, on the right side, a large, deep ulcer measuring 2×4 cm with a necrotic base. Two smaller ulcers were present in a similar position on the left perimalleolar areas. These were not quite as deep and were a bit cleaner. #### Laboratory Data - **Blood Sugar:** In excess of 330 mg% - **Chem Profile:** Otherwise unremarkable #### Hospital Course The patient’s ulcers were debrided in the ER. He was treated with normal saline wet-to-dry dressings four times per day. He learned his dressing care with instruction by the nursing staff and

Expert Solution