Surgery Soap: # 3

Date: 6/28/2023

Full Name: JC

Address:  NY, NY

Date of Birth: 1/25/1989

Location: Woodhull Hospital

Source of Information: 

Reliability: Self

Source of Referral: Spanish Interpreter # 80869

S

HPI: JC is a 34 y/o M ambulatory with crutches and with PMHx of DM2, PAD, proliferative diabetic retinopathy, and Hypertension. Patient is status post right femoral bypass on 1/30/2023, and right 2nd metatarsal amputation on 1/26/23. The patient is presenting to clinic today for wound care for mid part of the right medial thigh surgical site, that has not been healing well. Patient has been regularly following up with podiatry, and vascular clinic for wound packing. Patient is endorsing minimal pain, 2/10 that comes and goes when walking patient. Patient denies numbness and tingling to bilateral extremities, fever, chest pain, and shortness of breath.

PMHx: DM2, PAD, proliferative diabetic retinopathy, and Hypertension.

PSHx: Right femoral bypass, and right 2nd metatarsal amputation

Medication: Amlodipine 10mg, Atorvastatin 80mg, Insulin glargine 0.2ml, Insulin lispro 0.1mL, Rivaroxaban 2.5mg

Allergies: NKDA

FHx: Non-contributory

Social History: No history of smoking cigarettes or illicit drugs. Patient used to drink about 12 cans of beer per week.

ROS: Denies numbness and tingling to bilateral extremities, fever, chest pain, and shortness of breath.

O:

Vitals:

Vitals: T: 99.2°F (37.° C) oral | P: 99 BPM, regular | RR: 18 breaths/min, unlabored | BP: 120/65 mm Hg | SpO2: 99% room air | Wt: 189 lb (27.91 kg) |

Physical Exam:

General: Sitting on chair. Is alert, awake, and oriented x 3. In no

acute distress.

CV: RRR. S1 and S2 normal. No murmurs

Pulmonology: No respiratory distress, breathing comfortably on room air, no accessory muscle use

Abdomen: Abdomen is soft, non-tender to palpation.

Skin: Right medial thigh wound 6cm x 2cm 2 cm deep another wound is 3cm x 1cm, superficial.

musculoskeletal: Cervical back: Normal range of motion, and neck supple.

Peripheral Vascular system: B/l lower extremities are warm to touch. No pitting edema. 2+. Dorsalis pedis, and posterior tibial pulses are 2+.

Feet: Right second metatarsal amputation site is healing.

A:  JC is a 34 y/o M with PMHx of DM2, PAD, proliferative diabetic retinopathy, and Hypertension. Patient is status post right femoral bypass on 1/30/2023, and right 2nd metatarsal amputation on 1/26/23. The right medical thigh would is not healing significantly.

P:

  • Wet dry dressing medial thigh
  • FU with podiatry for right foot care
  • Pre-admission testing 7/6/2023
  • Right lower extremity angiogram with medial thigh debridement scheduled for 7/10/2023