Diabetes with neurological manifestations type II or unspecified type not stated as uncontrolled Ulcer of heel and midfoot Cellulitis and abscess of foot except toes Polyneuropathy in diabetes Atrial fibrillation Personal history of Methicillin resistant Staphylococcus aureus Long-term (current) use of anticoagulants Abdominal pain epigastric Unspecified essential hypertension Obesity unspecified Diarrhea Pure hypercholesterolemia
 
Name:  ___            Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
Foot ulcer pain and fever.
 
Major Surgical or Invasive Procedure:
___ line placement.

 
History of Present Illness:
Mr. ___ is a ___ male with DMII, Afib on coumadin 
(cardioverted in ___, HTN, and obesity here with fevers and 
diabetic foot ulcer. Patient noted this ulcer on the plantar 
aspect of his right foot two weeks ago after he pulled off some 
dead skin in that area. He has no feeling in either foot but has 
noted increase pain over his baseline. He went to his podiatrist 
(Dr. ___ at ___ 3 days prior to admission for some 
bothersome ulcers on L toe when podiatrist noted this wound and 
some associated red streaks extending up the foot. He debrided 
the wound and started patient on Augmentin. Wound culture 
reportedly sent at that time to patient's PCP at ___. The night 
prior to admission, patient woke up with fever to 101 and has 
been feeling generally unwell since debridement. The wound had 
been draining some yellow pus.  
In the ER, initial vitals 7 97.6 108 133/78 18 95% RA. Labs 
notable for WBC 12.7 (66%N), ESR 23, CRP 7.5, lactate and Chem 7 
normal. Foot XR showed no clear evidence of osteo. Blood 
cultures were sent and he received vanc and unasyn.  
Currently, patient has mild bilateral foot pain related to his 
neuropathy.  
REVIEW OF SYSTEMS:  
(+) Per HPI dry cough, chronic abdominal pain and diarrhea  
(-) Denies weight change, Denies headache, shortness of breath, 
or wheezing. Denies chest pain, chest pressure, palpitations, or 
weakness. Denies vomiting. Denies dysuria, frequency, or 
urgency.
 
Past Medical History:
Neuropathy
Insomnia
Hypercholesteremia
Hypertension
DM (diabetes mellitus) type II 
Atrial fibrillation s/p cardioversion ___
 
Social History:
___
Family History:
Mother had a large MI at age ___ and died from cancer/heart 
failure at age ___. Uncle had an MI in his late ___. Father's hx 
unknown.

 
Physical Exam:
EXAM ON ADMISSION:
VS: 97.8 124/68 92 18 96%RA 147.7kg  
GENERAL: well appearing obese man in NAD  
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM  
NECK: supple, no LAD, no JVD  
LUNGS: +scattered wheezes bilat, no rales, resp unlabored, no 
accessory muscle use  
HEART: RRR, no MRG, nl S1-S2  
ABDOMEN: normal bowel sounds, soft, non-distended, no rebound or 
guarding, no masses, mild ttp over upper abdomen b/l  
EXTREMITIES: no edema, 2+ pulses pt dp though cooler toes on R 
than L, numb feet b/l, 2cm in diameter shallow clean-based round 
ulcer on plantar surface of R foot w/some faint red streaking to 
dorsal surface of foot, two bandaged toes on L

EXAM ON DISCHARGE:
VS: 97.6 140/83 ___ 97%RA ___ 185
GENERAL: well appearing obese man in NAD  
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM  
NECK: supple, no LAD, no JVD  
LUNGS: clear to auscultation bilaterally, no rales, resp 
unlabored, no accessory muscle use  
HEART: regular, no MRG, nl S1-S2  
ABDOMEN: normal bowel sounds, obese, non-distended, no rebound 
or guarding, no masses
EXTREMITIES: no edema, 2+ pulses pt dp though cooler toes on R 
than L, numb feet b/l, 2cm in diameter shallow clean-based round 
ulcer on plantar surface of R foot w/no erythematous streaking, 
previous marks of streaking to dorsal surface of foot now 
resolved, L toe lesions without erythema or purulence 
 
Pertinent Results:
Labs on Admission:
___ 06:05PM BLOOD WBC-12.7* RBC-5.03 Hgb-15.2 Hct-44.8 
MCV-89 MCH-30.3 MCHC-34.0 RDW-12.6 Plt ___
___ 06:05PM BLOOD Neuts-66.6 ___ Monos-5.5 Eos-1.5 
Baso-0.7
___ 06:05PM BLOOD ESR-23*
___ 06:05PM BLOOD Glucose-86 UreaN-19 Creat-1.1 Na-141 
K-3.8 Cl-104 HCO3-25 AnGap-16
___ 06:22PM BLOOD Lactate-1.6
___ 08:10AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.3*
___ 08:10AM BLOOD ALT-26 AST-27 AlkPhos-78 TotBili-0.5
___ 08:10AM BLOOD ___ PTT-42.0* ___

Labs on Discharge:
___ 02:35AM BLOOD WBC-6.2 RBC-4.59* Hgb-13.9* Hct-41.1 
MCV-90 MCH-30.3 MCHC-33.9 RDW-12.3 Plt ___
___ 02:35AM BLOOD ___ PTT-38.9* ___
___ 02:35AM BLOOD Glucose-187* UreaN-10 Creat-0.9 Na-137 
K-4.6 Cl-100 HCO3-27 AnGap-15
___ 02:35AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.7
___ 02:35AM BLOOD Vanco-10.5

___ Blood cultures pending.

XR FOOT AP,LAT & OBL RIGHT Study Date of ___:
Soft tissue ulcer along the plantar and lateral aspect of the 
foot at the 
level of the midshaft of the metatarsals. No subcutaneous gas or 
definite radiographic evidence for osteomyelitis. Please note 
that MRI or bone scan is a more sensitive exam for the detection 
of osteomyelitis. 

CXR ___:
Low lung volumes, no pleural effusions. No parenchymal 
abnormality, in particular no evidence of pneumonia. Borderline 
size of the cardiac silhouette without pulmonary edema. No hilar 
or mediastinal 
abnormalities.
 
Brief Hospital Course:
___ with DMII c/b neuropathy here with a foot ulcer and fever.  
.
# Neuropathic Foot ulcer: Despite debridement by podiatry and 
oral antibiotics as an outpatient, patient developed fever and 
cellulitis concerning for resistant organism. Wound culture from 
OSH shows only skin flora ___ strep, diptherioids) but 
the patient reports a history of MRSA ulcer infection. Wound had 
some lymphangitic spread on admission but resolved with 
vanc/unasyn, now on vanc/augmentin. Low levels of inflammatory 
markers (see results) and foot XR without e/o osteomyelitis make 
this unlikely. Patient has good pulses. Podiatry recommended wet 
to dry betadine dressings and f/u with outpatient podiatry 
provider. Has been afebrile throughout admission. Has PICC for 
continued vanc/augmentin to complete total ___s 
outpatient. Vanc trough 10.5 (therapeutic).
.
# Afib: Missed coumadin dose ___ night of admission; INR 
___ -> ___ -> ___, below goal INR of ___. Was 
cardioverted in ___, regular rate and rhythm on exam. 
Continued coumadin and beta blocker. Patient will follow up in 
___ clinic ___ to follow-up INR. 
.
# Abdominal pain: Mild on admission and seemed resolved during 
admission. On last admission, pt was felt to have diverticulitis 
but current pain is located in the mid-epigastrium so 
differential more likely to include gastritis, GERD, 
gastroparesis, gallstones. Per patient he also has associated 
chronic diarrhea. LFTs/lipase unremarkable ___.
.
# DM2: continued home insulin regimen and restarted metformin on 
day prior to discharge. HgbA1c 8.5.   
# HL: continued statin. 
# HTN: continued BB, ACEi.
.
## Transitional Issues ##
1.  pending studies at discharge - blood cx's drawn ___, no 
growth to date, final pending
2.  complete course of antibiotics for cellulitis with IV 
Vancomycin and PO Augmentin for total 7 day course (___)
3.  f/u with outpt podiatrist for 5 metatarsal base resection
4.  f/u with ___ for INR monitoring and 
Coumadin adjustment.   
 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY 
2. Glargine 56 Units Breakfast
Glargine 30 Units Bedtime
Humalog 18 Units Breakfast
Humalog 18 Units Lunch
Humalog 18 Units Dinner
3. Metoprolol Tartrate 100 mg PO BID 
HOLD for SBP < 100, HR < 60  
4. Warfarin 8.75 mg PO 2X/WEEK (MO,FR) 
5. Lisinopril 10 mg PO DAILY 
HOLD for SBP < 100  
6. MetFORMIN (Glucophage) 1000 mg PO BID 
7. oxyCODONE-acetaminophen *NF* ___ mg ORAL Q6H severe pain 
8. Vitamin D 800 UNIT PO DAILY 
9. Warfarin 10 mg PO 5X/WEEK (___) 
10. Clonazepam 1 mg PO QHS:PRN insomnia 

 
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY 
2. Clonazepam 1 mg PO QHS:PRN insomnia 
3. Glargine 56 Units Breakfast
Glargine 30 Units Bedtime
Humalog 18 Units Breakfast
Humalog 18 Units Lunch
Humalog 18 Units Dinner
4. Lisinopril 10 mg PO DAILY 
5. Metoprolol Tartrate 100 mg PO BID 
6. Vitamin D 800 UNIT PO DAILY 
7. Warfarin 8.75 mg PO 2X/WEEK (MO,FR) 
8. Warfarin 10 mg PO 5X/WEEK (___) 
9. oxyCODONE-acetaminophen *NF* ___ mg ORAL Q6H severe pain 
10. MetFORMIN (Glucophage) 1000 mg PO BID 
11. Vancomycin 1500 mg IV Q 12H 
RX *vancomycin 750 mg 1500 mg(s) IV every twelve (12) hours Disp 
#*20 Vial Refills:*0
12. Amoxicillin-Clavulanic Acid ___ mg PO Q12H 
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by 
mouth every twelve (12) hours Disp #*10 Tablet Refills:*0

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Primary Diagnosis:
Neuropathic Diabetic Foot Ulcer c/b cellulitis
Seconadry Diagnosis:
Atrial Fibrillation s/p Cardioversion
HTN

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or 
wheelchair.

 
Discharge Instructions:
Dear Mr. ___,

It was a pleasure taking care of you at ___. You were admitted 
for treatment of cellulitis complicating an ulcer on your right 
foot. You were started on antibiotics to treat this infection. 
Your infection appears markedly improved and you are now safe to 
return home. 

You missed your ___ evening warfarin dose. Your INR was 1.6 
(below your goal of ___ for two days (on ___ and ___. Please 
follow up in ___ clinic and have your INR checked again on 
___, they are aware and will be expecting you.

We made the following changes to your medication:

Please START Vancomycin 
Please CONTINUE Augmentin

 
Followup Instructions:
___

{'Foot ulcer': ['Diabetes with neurological manifestations', 'Ulcer of heel and midfoot'], 'Fever': ['Cellulitis and abscess of foot', 'Polyneuropathy in diabetes'], 'Neuropathy': ['Diabetes with neurological manifestations', 'Polyneuropathy in diabetes'], 'Atrial fibrillation': ['Atrial fibrillation'], 'MRSA history': ['Personal history of Methicillin resistant Staphylococcus aureus'], 'Anticoagulant use': ['Long-term (current) use of anticoagulants'], 'Abdominal pain': ['Abdominal pain', 'epigastric'], 'Hypertension': ['Unspecified essential hypertension'], 'Obesity': ['Obesity', 'unspecified'], 'Diarrhea': ['Diarrhea'], 'Hypercholesterolemia': ['Pure hypercholesterolemia']}