Dermatology

DISCHARGE SUMMARY

This is a 33-year-old quadriplegic male.  Patient presents with a chief complaint, “I have a sore on my right hip.”  The patient states that several weeks ago he fell out of his wheelchair and injured the skin over his right hip.  The patient stated that this sore started in a pinpoint area and became larger and larger, and sought medical attention at my office.  Patient is a quadriplegic, was involved in a diving accident.  The patient states that he dove approximately 60 feet off of a cliff into approximately 4 feet of water.  At that time the patient severed his spinal cord in the area of C5-C6, and the patient has been quadriplegic since that time.

Physical examination reveals a very large decubitus ulcer in the area of his right hip.  This ulcer is very deep and has required a great deal of debridement and will require much more.  This patient is an obvious quadriplegic.  He has some motion of his shoulders and his elbows and has very little or no wrist flexion; however, he does have some wrist extension.

Laboratory studies were as follows:  On admission, his white count was 10.4 with 61% segmented neutrophils and 6 band neutrophils.  His urine was infected 4+ with bacteria; of course, this patient has had a chronic urinary tract infection.  Culture of the decubitus revealed a heavy growth of beta strep.  Another laboratory study was an SMA-20.  This patient had a total protein of 5.4, albumin level was 3.2, chloride was 106, and a total bilirubin was 1.2.

HOSPITAL COURSE

The patient was placed in the hospital, was placed on IV Mefoxin.  Several periods of extensive surgical debridement opened this ulcer to an area which is approximately 8 x 12 cm.  This ulcer was packed with a 50% solution of Betadine with a 50% solution of honey twice a day.  The patient was sent to a whirlpool treatment daily, and patient tolerated this procedure very well.

DISCHARGE INSTRUCTIONS

This patient is instructed to return to home, and I wrote an order for Home Health to consult and help in the care of this decubitus ulcer.  Instructions have been given and will be given to the mother in the care of this ulcer.  It should be noted that it was my opinion that this patient should be placed in a hospital where there is a special unit that cares for extensive decubitus patients.  They are also very adept at caring for quadriplegics with decubitus ulcers.  The patient stated that he refused to go to that facility.  I tried to convince his mother that he should be there, and his mother was even more adamant that the patient should return home and have care at the home.  I instructed both the patient and the mother that there could be severe sequelae to having a large open sore of this type, and after a great deal of discussion, it was clear that this patient refused to follow my suggestion.

FOOTNOTE

Line 7 (Page 1).  Present was changed to presents for
subject-verb agreement.  Is was deleted.

Line 9 (Page 1).  The redundant that was deleted.

Line 13 (Page 1).  With was changed to in.

Line 30 (Page 1).  The dictator said B strep, meaning beta strep or beta streptococcus.

Line 36 (Page 1).  Alternative:  I.V.

Lines 38, 39 (Page 1).  “The patient was” was corrected by the physician to “the ulcer was”.

Line 44 (Page 1).  The redundant for was deleted.

Line 45 (Page 1).  Home Health was capitalized because it is a division of an organization.

Line 45 (Page 1).  Help in the care with was edited to help in the care of.

Lines 47 (Page 1), 7 (Page 2).  The unnecessary period was deleted.