Cellulitis and abscess of leg except foot Ulcer of ankle Venous (peripheral) insufficiency unspecified Systemic lupus erythematosus Atrial fibrillation Unspecified essential hypertension Personal history of malignant neoplasm of prostate Knee joint replacement Other specified disorders of pancreatic internal secretion Adrenal cortical steroids causing adverse effects in therapeutic use
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: SURGERY
 
Allergies: 
Iodine; Iodine Containing
 
Attending: ___.
 
Chief Complaint:
Right lower leg ulcer and cellulitis
 
Major Surgical or Invasive Procedure:
None

 
History of Present Illness:
Mr. ___ is an ___ with DM and newly diagnosed lupus.  He 
was sent to the ED by his PCP for ___ ulcer & cellulitis x 2 
wks.  He claims that he scraped his leg with his cane and that 
it broke his skin 2 wks ago.  His right lower leg is painful to 
contact.  He denies fever and chills.  He was hospitalized at 
___ from last ___ to this ___ and treated with antibiotics per 
the patient.  He was discharged ___ and seen by his PCP today, 
who decided to send the patient to the ED.

 
Past Medical History:
Diabetes, ? paroxysmal A-Fib, HTN, lupus, prostate CA, s/p 
brachy therapy ___ (___), s/p R TKR, s/p CCY ___

 
Social History:
___
Family History:
Non-contributory
 
Physical Exam:
On Admission
PE: 96.9 89 157/50 16 99%RA
AAOx3 NAD
no carotid bruit
RR s1 s2
b/l rales
soft ND NT, no pulsating mass
b/l ___ edema, R>L
___ venous stasis ulcer, large; ant clean, post w/ dried eschar
___ cellulitis

On discharge:
Afebrile, VSS
Gen: no acute distress
Chest: RRR, lungs clear
Abd: soft, nontender, nondistended
Ext: B/L ___ edema (R>L), large venous stasis ulcer to right 
lower leg, erythema improved, large eschar on lateral aspect of 
right lower leg
 
Pertinent Results:
Admission labs:
___ 11:30PM BLOOD WBC-12.3* RBC-3.49* Hgb-9.7* Hct-30.7* 
MCV-88 MCH-27.7 MCHC-31.6 RDW-15.5 Plt ___
___ 11:30PM BLOOD ___ PTT-27.2 ___
___ 11:30PM BLOOD Glucose-303* UreaN-34* Creat-1.3* Na-143 
K-4.0 Cl-107 HCO3-26 AnGap-14
___ 11:30PM BLOOD ALT-22 AST-16 AlkPhos-58 TotBili-0.2

Discharge labs:
___ 06:40AM BLOOD WBC-9.0 RBC-3.40* Hgb-9.6* Hct-29.0* 
MCV-85 MCH-28.3 MCHC-33.1 RDW-16.2* Plt ___
___ 06:40AM BLOOD Glucose-84 UreaN-25* Creat-1.1 Na-138 
K-3.7 Cl-101 HCO3-30 AnGap-11

Plain films of right foot:  No osteomyelitis
 
Brief Hospital Course:
Mr. ___ was admitted with a right lower extremitu ulcer and 
cellulitis on ___.  A sample was sent for culture and he was 
started on intravenous antibiotics, Unasyn.  The culture came 
back with > 3 colony types.  He was switched to PO Bactrim on 
___.  He received dressing changes to both of his lower legs 
twice a day.  The discharge and erythema improved on the 
antibiotics.  A physical therapy consult was obtained and he was 
cleared for discharge.  He will be allowed to ambulate only 
essential distances, such as to the bathroom, but his is to 
remain in bed or a chair with his legs elevated at all times.  
His legs are to wrapped in ACE wraps.  He is being discharged to 
rehab to allow his right lower leg to demarcate and declare 
itself.  He may need a skin graft or a revascularization 
procedure at some point in the future.  He will follow up with 
Dr. ___ in 2 weeks to determine his treatment course.  

A rheumatology consult was obtained due to his recent diagnosis 
of lupus and they recommended a prednisone taper to 15mg daily. 
 
Medications on Admission:
prednisone, lasix, coumadin
 
Discharge Medications:
1. Oxycodone-Acetaminophen ___ mg Tablet Sig: ___ Tablets PO 
Q6H (every 6 hours) as needed for pain.  
2. Warfarin 2 mg Tablet Sig: One (1) Tablet PO 3X/WEEK 
(___).  
3. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO 4X/WEEK 
(___).  
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID 
(2 times a day).  
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for pain.  
7. Prednisone 20 mg Tablet Sig: One (1) Tablet PO daily () for 1 
doses: Give 1 dose on ___.  
8. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO daily (): 
Start on ___.  
9. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) 
Tablet PO BID (2 times a day): Continue until follow up with Dr. 
___.  
10. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units 
Subcutaneous once a day: Give at lunch.  
11. Insulin Lispro 100 unit/mL Solution Sig: sliding scale units 
Subcutaneous every six (6) hours.  

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Right lower leg ulcer and cellulitis
Systemic lupus erythematosus

 
Discharge Condition:
Good

 
Discharge Instructions:
Call your physician or return to the Emergency Department if you 
experience:
- fever > 101.5
- chills
- increasing purulent drainage from your ulcers
- increasing/spreading redness around your ulcers
- increasing pain in your lower extremities that does not 
resolve
- new onset chest pain or shortness of breath

Your coumadin was restarted on ___.  You must have your INR 
checked every day until it is therapeutic and then you can your 
INR checked weekly.

You were diagnosed with Systemic lupus erythematosus on this 
admission.  You were started on a prednisone taper.  You will be 
on 15mg of prednisone daily.  
 
Followup Instructions:
___

{'Right lower leg ulcer': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Cellulitis': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Painful contact': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Fever and chills': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Erythema improved': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Large venous stasis ulcer': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Erythema': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Edema': ['Cellulitis and abscess of leg', 'Ulcer of ankle', 'Venous (peripheral) insufficiency'], 'Lupus': ['Systemic lupus erythematosus']}