ADMITTING DIAGNOSIS: Pressure ulcer, stage IV.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old right-handed male with a history of paraplegia secondary to a spinal cord injury, who presented to the hospital with a stage IV pressure ulcer. Of note, the patient recently was found to have a very large abdominal aortic aneurysm. The patient reports that it was 11 cm in diameter. He subsequently required abdominal aortic aneurysmectomy. Subsequent to the surgical procedure, the patient developed a worsening pressure ulcer over the left hip area. He most recently presented to the hospital with an infection of that pressure ulcer. He has been treated with IV antibiotics. He now comes in for wound care, administration of IV antibiotics and aftercare related to his current medical condition.
PAST MEDICAL HISTORY: Diabetes; paraplegia; status post bilateral AKAs, remote; hypertension; hyperlipidemia; kidney stones; UTI.
ALLERGIES: No known drug allergies.
MEDICATIONS: Zyvox, Primaxin, fluconazole, Benadryl, metoprolol, Tricor, aspirin, morphine, Vicodin, Tylenol, hydrochlorothiazide, lactobacillus, Nexium, Actos and multivitamins.
FAMILY HISTORY: Not obtained.
SOCIAL HISTORY: The patient is married and lives with his wife, works full time. The patient was able to transfer independently premorbidly.
REVIEW OF SYSTEMS: The dressing changes are painful. His bowel and bladder program he managed by himself previously. Overall, the patient is fairly encouraged. He states he has not been in his wheelchair for 2 weeks for pressure relief.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.6, blood pressure 140/84, pulse 80, respiratory rate 18.
GENERAL: The patient is awake, alert, pleasant and cooperative, in no distress.
HEENT: Normocephalic, atraumatic. Extraocular muscles intact. Oropharynx is clear.
NECK: Supple.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally. No wheezing, rhonchi or rales.
ABDOMEN: Positive bowel sounds, soft, nontender. The midline laparotomy incision is well approximated mostly. There is a small area measuring several centimeters in length at the inferior aspect of the incision line, which is packed. He has a large dressing over the left hip area, again, not taken down. He has bilateral AKAs.
LABORATORY DATA: Most recent labs show a white count of 6.8, hemoglobin 9.6, platelets 620, creatinine 1.2.
IMPRESSION AND PLAN:
1. Pressure ulcer, reported as stage IV: Further evaluation to be performed by the wound care team in the morning. The patient will have an AccuMax mattress with pump. We will have the wound care team evaluate. We will continue with local wound care. Overnight, we will do wet-to-dry dressings. With regards to the infection and the pressure ulcer, he will continue with the IV antibiotics as noted above.
2. Diabetes: The patient will be on a no concentrated carbohydrate diet. Will cover with sliding scale insulin with frequent Accu-Cheks as needed.
The patient had AAA that was resected surgically. There is still a small opening along the incision line. Wound care will manage.
4. Hypercholesterolemia: The patient is managed with medications as above.
5. Status post bilateral AKAs, remote.
6. Skin: Again, the wound care team will follow. At present, we will make the patient bed rest.
7. Further workup, evaluation and treatment: Deferred to Dr. Doe.
8. DVT prophylaxis: The patient will be continued on low-molecular-weight heparin while here.
