DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
CHIEF COMPLAINT: Cellulitis of the left leg.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who has a history of cellulitis of the left leg over the last several days, increased erythema, swelling, and pain in the left lower extremity.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure is 152/78, pulse 82, respirations 22, and temperature 97.8 degrees. HEENT: Pupils react to light. Disks are flat. Sclerae are clear. Oral mucosa is dry. Posterior pharynx is without thrush. Tympanic membranes are without lesions. NECK: Supple. No JVD, carotid bruits, or cervical adenopathy. LUNGS: Show bilateral rhonchi. CARDIOVASCULAR: Shows normal S1 and S2. ABDOMEN: Bowel sounds are present. No guarding or masses in the abdomen. EXTREMITIES: Show erythema of the left lower extremity with scars from scratching. There is 1+ swelling of the skin. Peripheral pulses are 1+. There is tenderness on the dorsum of the left foot. No cyanosis is noted at present. Onychomycosis is present bilaterally. NEUROLOGIC: She is oriented. Motor and sensory are intact.
HOSPITAL COURSE: The patient was admitted with cellulitis of the left leg and started on Kefzol 1 g intravenously q.8 hours, Percocet 5 mg one tablet q.6 hours p.r.n., Synthroid 0.125 mg daily, Restoril 30 mg nightly, Fosamax 70 mg every week, normal saline at 60 mL an hour, Tenormin 50 mg daily, and Ditropan XL 10 mg daily. She was seen in consultation for depression, and it was recommended that we initiate Effexor XR 37.5 mg daily with Xanax 0.25 mg p.r.n. anxiety. She was seen by Podiatry for onychomycosis, and they did avulse the nail plates and debrided the nails. She was seen by Dr. John Doe for pancytopenia. He recommended a bone marrow, which the patient refused. The patient over the course of the next several days still had erythema of her foot. We continued with antibiotic therapy. Effexor was increased to 75 mg daily.
She was noted to have increased pedal edema and Lasix 40 mg b.i.d. was started, continuing with Kefzol 1 g intravenously q.8 hours, Ditropan XL 10 mg daily, Effexor 75 mg daily, Flexeril 5 mg b.i.d., Xanax 0.25 mg t.i.d., Fosamax 70 mg every week, Restoril 30 mg nightly, Demerol 25 mg q.4 hours, Synthroid 0.125 mg daily, and Tenormin 50 mg daily. By MM/DD/YYYY, erythema of the lower extremity was better. It was felt that the patient should not go home at present but should go for rehabilitation prior to going home and so was transferred under the care of Dr. Jane Doe. The patient was transferred in good condition, good prognosis, on a no-added-salt diet, activity as tolerated.
The patient was transferred on Lasix 40 mg b.i.d., Kefzol 1 g intravenously q.8 hours, Ditropan XL 10 mg daily, Effexor 75 mg daily, Flexeril 5 mg b.i.d., Xanax 0.25 mg t.i.d., Fosamax 70 mg every week, Restoril 30 mg nightly, Percocet one to two tablets q.6 hours p.r.n., Synthroid 0.125 mg daily, and Tenormin 50 mg daily. We will follow her upon her release from the rehab facility.
LABORATORY DATA: Hemoglobin 10.4, hematocrit 30.8, white blood cell count 2100 and platelet count 98,000. Sodium 141, potassium 4.2, chloride 108, CO2 of 26, BUN 19, creatinine 1.1, glucose 96, protein 8.1, albumin 3.6, calcium 9.4, bilirubin 0.92, AST 70, ALT 54, alkaline phosphatase 132, triglyceride 82, cholesterol 141, HDL 46, LDL 78, and T4 of 13.4. UA showed no glucose, no nitrites, no protein, and no blood. TSH was 1.22.
Chest x-ray showed no infiltrate. EKG showed normal sinus rhythm.
DISCHARGE DIAGNOSES:
1. Cellulitis of the left leg.
2. Depression.
3. Pancytopenia.
4. Degenerative joint disease.
5. Hypertension.
6. Congestive heart failure.
