Answered: If the patient's wounds do not heal…

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

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Transcribed Image Text:Discharge Summary Patient 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 that were sustained. 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: Patient has a positive history of diabetes mellitus. Allergies-none known. No known history of cigarette smoking, although he is a pipe smoker; no history of previous cardiac risk. Surgeries - significant for appendectomy, tonsillectomy. In September 1984 the patient had a foot ulcer treated non- surgically at St. Joseph's Hospital. Review of Systems: Negative Physical Exam: Temperature-98; 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 2x4 cm. Its base was necrotic. Two smaller ulcers were present in a similar position on the left perimalleolar areas. These were not quite so deep and were quite 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 was discharged on 10/18/85 after being informed that these ulcers may not spontaneously heal. Discharge Instructions: He will be given a trial of out-patient care. If the wounds do not demonstrate satisfactory healing within the next 2-3 weeks, he will be re-admitted for skin grafting procedures. The patient is aware of this and agrees to this course of action. He will be seen in my office in four days. It should be noted that Dr. Finkenstadt, his family physician, followed the patient throughout his hospital course and managed his insulin dosage. The patient was instructed to call Dr. Finkenstadt after discharge to ensure that his insulin dose is maintained at the proper dosage.