DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old diabetic female who is here for a followup. She denies any new complaints. She is clinically doing well.
PAST MEDICAL HISTORY: Unchanged.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 98.2, respiratory rate is 20, pulse is 90, and blood pressure is 120/64. Her blood sugar today was 122.
INTEGUMENT: On examination of the left posterior thigh, the wound is 0.4 x 0.5 x 0.1 cm, the left shin wound is 9.5 x 12.6 x 0.1 cm, the right abdominal wound is 0.3 x 1.2 x 0.1, and right lateral leg wound is 2 x 1 x 0.1 cm.
TREATMENT: After the application of 5% lidocaine for topical anesthesia, under clean surgical technique, the left posterior thigh wound, the left shin wound, and the right abdominal wound were all debrided with a curette into the subcutaneous tissue. The patient tolerated the procedure well. Hemostasis was obtained by pressure alone. Post-debridement measurements for the left posterior thigh wound were 0.4 x 0.6 x 0.2, left shin wound was 9.5 x 12.7 x 0.2, and the right abdominal wound was 0.4 x 1.3 x 0.2. The patient tolerated the procedure well. Hemostasis was obtained by pressure alone.
IMPRESSION: Venous insufficiency ulceration involving lower extremities and decubitus ulcer involving the posterior thigh area. The decubitus ulcers on the thigh were doing better, but she has a small opening since last week on the left posterior thigh. The right leg appears to be doing a little bit better. After the debridement, it was strongly emphasized that no Band-Aids be applied to her skin. When she came in today, she had a Band-Aid on her right thigh, which when taken off started to bleed, as she is on Coumadin. Also, the patient is using lidocaine ointment, so we have asked not to use any lidocaine ointment to the abdominal folds or buttock area. The patient can use it in the perineal area as has been recommended by her primary physician. Bactroban with betamethasone with barrier cream should be applied to the periulcer skin on the right and left shin with Acticoat Flex to ulcer, Xtrasorb, ABD, 3M Coban. The right abdominal wound should be covered with barrier cream, Allevyn Gentle to be changed every two to three days. The leg dressings do not need to be changed. Zinc barrier cream should be applied liberally to the right and left posterior thigh, abdominal folds, and buttock b.i.d., Allevyn Gentle to the left posterior thigh or cream to be changed every two to three days. All this was discussed with the patient and spouse in detail. The patient will come back and see us next Wednesday.
Wound Care / Pain Clinic Terms
DATE OF SERVICE: MM/DD/YYYY
This (XX)-year-old female has been treated for multiple venous stasis ulcers of the left lower extremity. The patient has been treated with an Acticoat dressing and a PolyMem foam over the Acticoat and a Profore wrap. She is having this changed twice weekly, but because of the weather, she was unable to make it into the wound center this past Thursday. When she arrived today, there was a considerable odor to the wound. The patient has had no pain from the wound. She has otherwise had no change in her medical condition or her medications.
PHYSICAL EXAMINATION:
VITAL SIGNS: Her exam today reveals blood pressure of 142/82, pulse of 72, respirations 18, and temperature 98.4 tympanically.
EXTREMITIES: Examination of the left lower extremity reveals that the ulcer, which was located laterally, has now completely healed. There is some dry scale that we removed from this area, but there was no open ulceration noted. The ulcer on the medial aspect of the left lower extremity is healing well as well. The ulcer measures 11.2 x 4.8 x 0.2 cm. There is some hypertrophic granulation tissue in the ulcer base, which we have debrided sharply with a sharp curette. Bleeding was controlled with pressure alone.
An Acticoat 3 dressing followed by PolyMem foam and a Profore wrap was then placed on the leg. The patient was asked to return to the wound center in another four days for re-examination.
DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This (XX)-year-old female presents to the Wound Care Clinic for followup treatment of a chronic nonhealing ulceration to her right leg. The patient states that the leg has not been painful and that she feels it is improving. She did not have any difficulties with the bandage.
PHYSICAL EXAMINATION:
VITAL SIGNS: Stable, patient is afebrile.
INTEGUMENT: Reveals full-thickness ulceration, medial right leg, with a large amount of beefy red granulation tissue and a small amount of serosanguineous drainage present. There is no fibrotic or black necrotic tissue noted. There is a hyperpigmentation that remains to the periwound with no signs of infection noted. The ulceration measures 1.6 x 1.2 x 0.2 cm in diameter.
IMPRESSION: Chronic nonhealing ulcer, right leg.
PLAN: Following examination of the right leg, 5% viscous lidocaine was applied for topical anesthesia. The right leg ulceration was then debrided through the level of the subcutaneous tissue. The patient tolerated this uneventfully. A new piece of OASIS was affixed to the wound surgically. Mepitel and Xenaderm were applied to the periwound. An Allevyn foam dressing was applied for compression followed by a Profore four-layer compression bandage. The patient will follow up in the Wound Care Clinic in one week.
DATE OF SERVICE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This (XX)-year-old male is being treated in the Wound Center for a Wagner grade 2 ulcer of the tip of the toe and dorsum of the left ankle. The patient has been applying Regranex to the ulcers. Although, Dr. John Doe’s note stated that the patient was going to be applying Prisma and Regranex, the patient does not have any Prisma at home. The patient has not had any pain from the ulcers. His medical health has not changed since his last visit and his medications have not changed.
PHYSICAL EXAMINATION:
VITAL SIGNS: Today reveals a blood pressure of 132/72, pulse of 74, respirations 18, and temperature is 97.2 tympanically. His blood sugar is 132.
EXTREMITIES: Examination of an ulcer on the shin reveals no open ulceration but merely a crust over the ulcerated area. The same is true of the lesion on the dorsum of the left ankle, which is crusted.
TREATMENT AND PLAN: We debrided this in a partial-thickness fashion removing some of the crust from the edges, and the skin under the crust was healed. The crust is firmly in place over the central portion of the ulcer and we did not disturb it. There is also a 0.5 x 0.3 x 0.2 cm ulcer on the tip of the left second toe, which we debrided into the subcutaneous tissue plane sharply. We also removed a thick callus from the tip of the toe. After debridement, there was a quite a bit of bleeding, which was cauterized with silver nitrate. We then applied Prisma to this ulcer and have advised the patient to apply Regranex and Prisma to the ulcer on a daily basis. The patient was given the Prisma that was used to treat him. The patient was asked to return to the Wound Center in one week for followup examination.
