Patient presents today with his wife for follow-up on shin wounds.
HPI:
Patient ended up with 2 wounds, 1 to his left shin in addition to 1 to his right shin. The left shin appears to be healing, it is scabbed over.
The wound on the right shin occurred about 2 weeks ago when patient hit his leg on his toolbox. He was seen in clinic on May 22nd and started on antibiotics after a previous trip. He started on clindamycin. Patient finished the clindamycin, he is now on Bactrim for 2 more days. Patient denies any fever, shortness of breath, or excesses drainage from the wound. His wife has been doing the dressing changes daily at home. She feels comfortable doing this work.
At the end of the appointment, patient’s wife reported his irregular heartbeat. She feels at times he will appear to be short of breath and look fatigued when he is sitting in a chair, when she will check his heart rate, she feels that it is irregular and into the 120s. Patient did …show more content…
His blood sugars usually run between 120s and 160s. Patient and wife have been educated on the importance of good blood sugar control for optimal wound healing.
Problem list/Assessment and Plan:
Irregular heart rhythm: Possible paroxysmal atrial fibrillation given report of symptoms. We will refer patient to cardiology for a Holter monitor. Patient denies symptoms but his wife feels that he does get short of breath and appear fatigued while sitting in a chair with this irregular rhythm.
Abrasion of anterior right lower leg: (Next paragraph) Patient and wife educated to signs of infection and alarm symptom including fever, pain, and increased drainage. Patient to finish Bactrim in 2 days. Patient to follow up in clinic in 2 weeks to monitor site condition of wound.
Patient educated to change the dressing when needed for soilage of the bandage, otherwise to change 3 times a week and to clean the wound. Okay to shower, let the water drain over the wound, do not scrub the
HPI:
Patient ended up with 2 wounds, 1 to his left shin in addition to 1 to his right shin. The left shin appears to be healing, it is scabbed over.
The wound on the right shin occurred about 2 weeks ago when patient hit his leg on his toolbox. He was seen in clinic on May 22nd and started on antibiotics after a previous trip. He started on clindamycin. Patient finished the clindamycin, he is now on Bactrim for 2 more days. Patient denies any fever, shortness of breath, or excesses drainage from the wound. His wife has been doing the dressing changes daily at home. She feels comfortable doing this work.
At the end of the appointment, patient’s wife reported his irregular heartbeat. She feels at times he will appear to be short of breath and look fatigued when he is sitting in a chair, when she will check his heart rate, she feels that it is irregular and into the 120s. Patient did …show more content…
His blood sugars usually run between 120s and 160s. Patient and wife have been educated on the importance of good blood sugar control for optimal wound healing.
Problem list/Assessment and Plan:
Irregular heart rhythm: Possible paroxysmal atrial fibrillation given report of symptoms. We will refer patient to cardiology for a Holter monitor. Patient denies symptoms but his wife feels that he does get short of breath and appear fatigued while sitting in a chair with this irregular rhythm.
Abrasion of anterior right lower leg: (Next paragraph) Patient and wife educated to signs of infection and alarm symptom including fever, pain, and increased drainage. Patient to finish Bactrim in 2 days. Patient to follow up in clinic in 2 weeks to monitor site condition of wound.
Patient educated to change the dressing when needed for soilage of the bandage, otherwise to change 3 times a week and to clean the wound. Okay to shower, let the water drain over the wound, do not scrub the