Dermatology Case Study

CONSULTATION

The patient is an elderly, pleasant female who is quite cooperative.  She was admitted to the hospital because of cellulitis of the right lower extremity.  There has been blistering of the area on the dorsum of the foot as well as higher up towards the ankle.  She has redness extending all the way up to the mid-pretibial area.  There is no history of lymphadenopathy, and judging from the chart, she has been afebrile.  She was started, after finding out that her white count was abnormal, on Cefobid and tobramycin and infectious disease consultation sought.

PHYSICAL EXAMINATION

Exam today shows a temperature of 37 degrees Centigrade, a blood pressure of 130/70, a respiratory rate of 20, and pulse rate of 80.

GENERAL APPEARANCE:  An elderly female in no acute distress.

HEAD AND ENT:  Grossly negative.

NECK:  Supple.

LUNGS:  Clear and resonant.

HEART:  Grade 1 systolic murmur; otherwise negative.

ABDOMEN:  Scars of surgery.  The abdomen is not obese but protruding.  She has some left lower quadrant discomfort that is mild.

VAGINAL AND RECTAL:  Not done.

LYMPH NODES:  No enlargement.

Exam of the extremities reveals blistering cellulitis over the dorsum of the foot with swelling and extension of the abnormal coloration to the mid-pretibial area.  The foot appears warmer than the other.

After sterile preparation the 2 blisters were aspirated, 0.2 cc of fluid was taken out, and this was sent for Gram stain and culture.

IMPRESSION

Probable streptococcus cellulitis.

DISCUSSION

The patient has had a Gram stain done yesterday, and it does show gram-positive cocci.  This may well be staph, but I think we should give her penicillin till the culture reports are out.  The blistering is typical of strep.  I would go ahead and give her
2 million q.6h. of the penicillin and modify therapy according to culture report.

I thank you for allowing me to participate in the care of this pleasant, elderly female and will reassess p.r.n.

FOOTNOTE

Line 42.  The brief form strep was expanded to streptococcus in the Impression.

Dermatology Case Study

CHART NOTE

Patient is 36 years old and has a 16-year history of patchy psoriasis.  On examination today he has a localized area of psoriasis on the right frontal scalp and involvement of both elbows but is otherwise clear.  The impression today is stable plaque psoriasis.

For the scalp he was started on Neutrogena T/Gel shampoo to be used on a daily basis, with Diprolene lotion to be applied b.i.d. until clear; 2 ounces were dispensed plus 3 refills.  For the elbow lesions he was given a refill of the Diprolene ointment to be applied b.i.d. when active, and the left elbow was injected and one-third of the right elbow was injected using a total of
4 cc of 2.5 mg/cc of Kenalog diluted in solution.  The patient is to recheck in 1 month so that the injections can be completed.

FOOTNOTE

Line 19.  Two and a half was changed to 2.5 because metric numbers use decimals, not fractions.

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.

Dermatology Case Study

To Whom It May Concern,

I am sending you this registered letter so that I have legally discharged to you my responsibility in regard to the skin cancer which we discussed on your last visit.  My office manager advises me that you are currently trying to arrange some sort of insurance coverage.

It is my obligation to advise you clearly that this tumor is a cancer, that it should be treated promptly, in my opinion within the next 4 to 6 weeks.  I have already discussed with you at length the treatment which I feel is appropriate, that is, excision under frozen control and closure with an advancement flap.  Delay in having this done can result in a less satisfactory cosmetic result, greater expense, and if it is delayed long enough, could result in a tumor which becomes unresectable and could lead to severe disfigurement, and in very rare cases these tumors have, when uncontrolled, resulted in a patient’s death.

I therefore have an obligation to urge you to seek prompt treatment in regard to this lesion.

Very truly yours,

Name.

FOOTNOTE

Line 13.  The physician who dictated this letter originally addressed it To Whom It May Concern because it was to be sent to an insurance company by the patient.  Out of context, it appears to be an instruction error.  Therefore, it would be acceptable for the transcriptionist to supply a different salutation.

Line 23.  The dictated word and was deleted to shorten the sentence.

Line 23.  Alternative:  4-6 weeks.

Dermatology Case Study 13

CHART NOTE

This patient has had multiple problems with both hips, having undergone multiple surgical procedures, including an attempt at left total hip arthroplasty, without success.  Patient had developed a trophic ulcer or stasis ulcer in the area in question and has been treated in our office for debridement of the same.  He shows no improvement particularly, and now there is good mobility of the skin.  I have advised that he be admitted to the hospital for excision of this ulcer of the left hip region.  Patient agrees to this, and we will make the necessary arrangements for his elective admission later next week.