Type 2 diabetes mellitus with other specified complication Other acute osteomyelitis right ankle and foot Type 2 diabetes mellitus with hyperglycemia Non-pressure chronic ulcer of other part of right foot with unspecified severity Essential (primary) hypertension Long term (current) use of insulin Type 2 diabetes mellitus with foot ulcer Crushing injury of right lesser toe(s) initial encounter Other cause of strike by thrown projected or falling object initial encounter Garden or yard of other non-institutional residence as the place of occurrence of the external cause
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: PODIATRY
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___
 
Chief Complaint:
R foot ulcer
 
Major Surgical or Invasive Procedure:
___: R ___ digit arthroplasty

 
History of Present Illness:
This patient is a ___ year old male with PMH significant for 
uncontrolled type II diabetes and hypertension with a right 
fourth to infection. Patient recalls doing yard work on ___ 
when he dropped a heavy object on his foot. He then travelled to 
___ for a business trip and a on ___ noticed an 
ulcer with increasing redness and drainage on his right fourth 
toe. He presented to an emergency room in ___, where he was 
admitted for IV antibiotics. Surgical intervention was discussed 
during his admission, but an infectious disease physician 
recommended he fly home to ___ and be seen immediately. He 
was discharged on a course of Augmentin which he has been taking 
and states some of the redness has improved. Patients admits to 
being diabetic and that his blood sugars have been under poor 
control. His most recent HbA1c was 12.3%. He denies any recent 
nausea, vomiting, fever, chills, shortness of breath, or chest 
pain.
 
Past Medical History:
HTN, DMII

 
Social History:
___
Family History:
Significant for diabetes and heart disease
 
Physical Exam:
Admission Physical Examination
General: Awake, alert, oriented x3. No acute distress
HEENT: MMM, neck supple, NTAC
Cardiac: extremities well perfused
Lungs: No respiratory distress
Abd: Soft, non-tender, non-distended 
Lower extremity exam: ___ pulses palpable b/l. Capillary 
refill time < 3 seconds to the digits b/l. Skin temperature warm 
to cool from proximal tibia to distal digits bilaterally. 
Protective sensation diminished b/l. Ulcer noted to the lateral 
aspect of the fourth digit that probes deeply. Scant amount of 
purulent drainage expressed from the fourth digit ulcer. Right 
fourth digit appear erythematous and edematous with sloughing 
skin.  Erythema note to the right fourth toe extending to the 
right dorsal foot, outline by previous hospital. Distal aspect 
of the fourth digit appears dusky in color without capillary 
refill. Mild tenderness with palpation of the right fourth 
digit. 

Discharge Physical Exam:
 
Pertinent Results:
___ 09:29PM BLOOD WBC-7.3 RBC-4.15* Hgb-12.5* Hct-35.7* 
MCV-86 MCH-30.1 MCHC-35.0 RDW-11.5 RDWSD-36.1 Plt ___
___ 09:29PM BLOOD Neuts-58.1 ___ Monos-9.2 Eos-1.8 
Baso-0.1 Im ___ AbsNeut-4.25 AbsLymp-2.23 AbsMono-0.67 
AbsEos-0.13 AbsBaso-0.01
___ 09:29PM BLOOD Plt ___
___ 09:29PM BLOOD Glucose-286* UreaN-17 Creat-0.8 Na-136 
K-4.1 Cl-99 HCO3-24 AnGap-17
___ 09:29PM BLOOD Calcium-9.2 Phos-2.7 Mg-1.8
___ 09:29PM BLOOD CRP-18.7*

Right foot radiograph ___: 
FINDINGS:  
  
Soft tissue swelling at the fourth toe is present.  No overt 
bone destruction 
or periosteal reaction. 
  
Mild degenerative changes are seen at the first MTP joint, 
fourth TMT joint, first TMT joint.  Plantar and posterior 
calcaneal spurs are seen.  Bipartite lateral sesamoid at first 
MTP. 
  
IMPRESSION:  
  
Soft tissue swelling at the fourth toe.  No overt evidence of 
osteomyelitis.  Additional findings as above. 

 
Brief Hospital Course:
The patient was admitted to the podiatric surgery service from 
clinic on ___ for a R foot infection. On admission, he was 
started on broad spectrum antibiotics. The patient was brought 
to the operating room on ___ for a Right ___ digit 
arthoplasty, which the patient tolerated well. For full details 
of the procedure, please see the separately dictated operative 
report. The patient was taken to the PACU in stable condition 
and was transferred back to the floor after satisfactory 
recovery from anesthesia. 

Throughout his hospital stay, the patient remained afebrile with 
stable vital signs; pain was well controlled oral pain 
medication on a PRN basis.  The patient remained stable from 
both a cardiovascular and pulmonary standpoint. He was placed on 
broad spectrum antibiotics while hospitalized and discharged 
with oral antibiotics. His intake and output were closely 
monitored and noted to be adequate. The patient received 
subcutaneous heparin throughout admission; early and frequent 
ambulation were strongly encouraged. The patient had 
hyperglycemia throughout his stay, and was seen by a member of 
the ___ Diabetes Team and his blood glucose levels improved. 

The patient was subsequently discharged to home on POD 2 with 
vital signs stable and vascular status intact to right foot. The 
patient received discharge teaching and follow-up instructions 
with understanding verbalized and agreement with the discharge 
plan.

 
Medications on Admission:
1. Metformin 1000mg BID
2. Lisinopril 40mg
3. Simvastatin 40mg

 
Discharge Medications:
1.  Acetaminophen ___ mg PO Q6H:PRN Pain - Mild  
2.  Ciprofloxacin HCl 750 mg PO Q12H 
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day 
Disp #*20 Tablet Refills:*0 
3.  Doxycycline Hyclate 100 mg PO Q12H 
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day 
Disp #*20 Tablet Refills:*0 
4.  Glargine 30 Units Dinner
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR 
30 Units before DINR; Disp #*1 Syringe Refills:*0 
5.  Lisinopril 40 mg PO DAILY  
6.  MetFORMIN (Glucophage) 1000 mg PO BID  
7.  Simvastatin 20 mg PO QPM  

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
R foot ulcer

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Mr. ___,

It was a pleasure taking care of you at ___. You were admitted 
to the Podiatric Surgery service for your right foot surgery. 
You were given IV antibiotics while here. You are being 
discharged home with the following instructions: 

ACTIVITY:
There are restrictions on activity. Please remain weight bearing 
to  your R heel in a surgical shoe until your follow up 
appointment. You should keep this site elevated when ever 
possible (above the level of the heart!) 

No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever 
greater than 101 degrees, chills, increased redness, or pus 
draining from the incision site. If you experience any of these 
or bleeding at the incision site, CALL THE DOCTOR.

Exercise:
Limit strenuous activity for 6 weeks.
No heavy lifting greater than 20 pounds for the next ___ days.
Try to keep leg elevated when able.

BATHING/SHOWERING:
You may shower immediately upon coming home, but you must keep 
your dressing CLEAN, DRY and INTACT. You can use a shower bag 
taped around your ankle/leg or hang your foot/leg outside of the 
bathtub. 

Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 
weeks after surgery or until cleared by your physician.

MEDICATIONS:
Unless told otherwise you should resume taking all of the 
medications you were taking before surgery. 
Remember that narcotic pain meds can be constipating and you 
should increase the fluid and bulk foods in your diet. (Check 
with your physician if you have fluid restrictions.) If you feel 
that you are constipated, do not strain at the toilet. You may 
use over the counter Metamucil or Milk of Magnesia. Appetite 
suppression may occur; this will improve with time. Eat small 
balanced meals throughout the day. 

DIET:
There are no special restrictions on your diet postoperatively. 
Poor appetite is not unusual for several weeks and small, 
frequent meals may be preferred.

FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments. 
If a follow up appointment was not made prior to your discharge, 
please call the office on the first working day after your 
discharge from the hospital to schedule a follow-up visit. This 
should be scheduled on the calendar for seven to fourteen days 
after discharge. Normal office hours are ___ 
through ___.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR 
QUESTIONS THAT MIGHT ARISE.

 
Followup Instructions:
___

{'ulcer': ['Type 2 diabetes mellitus with foot ulcer', 'Non-pressure chronic ulcer of other part of right foot with unspecified severity'], 'redness': ['Type 2 diabetes mellitus with foot ulcer', 'Non-pressure chronic ulcer of other part of right foot with unspecified severity'], 'drainage': ['Type 2 diabetes mellitus with foot ulcer', 'Non-pressure chronic ulcer of other part of right foot with unspecified severity'], 'infection': ['Type 2 diabetes mellitus with foot ulcer', 'Other acute osteomyelitis, right ankle and foot'], 'uncontrolled diabetes': ['Type 2 diabetes mellitus with other specified complication', 'Type 2 diabetes mellitus with hyperglycemia'], 'hypertension': ['Essential (primary) hypertension']}