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Wound Care Medical Transcription Sample Reports

DATE OF SERVICE:  MM/DD/YYYY

HISTORY OF PRESENT ILLNESS: This patient returns to wound clinic for followup on chronic ulceration in the plantar and lateral aspect of left foot. She missed her last appointment. She denies new complaints at this visit. Denies nausea, vomiting, fever or chills. The patient is continuing dressings with Prisma on the medial aspect of the left foot and Panafil on the outside of her left foot. She denies new complaints.

PHYSICAL EXAMINATION: Reveals ulcerations present on the patient's left foot and the medial ulceration measured 2.5 x 1.5; this is on the medial left foot. There is no sinus tract or tunneling. There is small amount of undermining noted at 2 to 5 o'clock. There is a large amount of serous drainage coming from the wound. There is large amount of red granulation tissue with the large amount of hyperkeratotic tissue surrounding the wound. No black or necrotic tissue. No exposed tendon or bone. There is no periwound edema, erythema or malodor. On the left plantar second metatarsal head, there is also an ulceration measuring 0.6 x 0.6 x 0.2. Again, there is no sinus tract or tunneling. No undermining. There is moderate amount of serous drainage coming from the wound. There is a large amount of red granulation tissue with small amount of fibrous tissue. No black or necrotic tissue. No exposed tendon or bone. No periwound edema, erythema or malodor. There is an ulceration present in the lateral aspect of the left foot measuring 1.3 x 1.3 x 0.2. There is no sinus tract or tunneling. No undermining. There is a moderate amount of serous exudate coming from this wound with small amount of pale granulation tissue with large amount of yellow slough and fibrous tissue. No black or necrotic tissue. No exposed tendon or bone. No periwound edema, erythema or malodor.

On vascular examination, she has +1/4 palpable pedal pulses bilaterally. Capillary fill time less than 3 seconds x5 bilaterally. On neurological examination, she has decreased sensation to Semmes-Weinstein monofilament of 5.06 to the level of the malleoli bilaterally.

ASSESSMENT:
1.  Grade 2 Wagner ulceration on the medial aspect of the patient's left foot, a grade 2 Wagner ulceration on the lateral aspect of the patient's left foot, and a grade 2 ulceration on the planter second metatarsal head, left foot.
2.  Peripheral neuropathy.
3.  Diabetes mellitus.

PROCEDURE PERFORMED: I examined and evaluated the patient. I discussed the etiology of these ulcerations and treatment protocol. I aggressively debrided these ulcerations into the subcutaneous layer of the wound involving all fibrous and nonviable tissue. I applied Panafil to the outside of the left foot and Prisma to the plantar and medial aspect of the left foot.

PLAN: I advised the patient to continue doing daily dressing change and to return to the wound clinic in 1 week for followup visit. Continue the off-loading device in her shoe.

DATE OF SERVICE:  MM/DD/YYYY

This patient has a dehisced midline wound, which we have been treating on an outpatient basis with the wound VAC. There has been substantial improvement in the wound. There still is undermining on the patient's right upper quadrant, of this wound, of 3 cm for a maximum of 5 cm 12 o'clock on the left upper hemisphere. This also had been undermined last week and now appears to be adherent. The overall cutaneous wound is smaller, and the wound is contracting with much better looking granulation tissue. There is no longer the thick white slough, which had been present at the beginning. So overall, there is continued improvement. The patient's general sense of health and well-being has been good as well. The patient indicates that wound VAC has been able to stay in place, which had been a problem for the first couple of weeks. That is no longer an issue.

We have curetted the wound base and the sides, including curetting the undermined area, into bleeding subcutaneous tissue. Hemostasis was achieved with pressure. We will continue to use the wound VAC. We have increased it to 150 cm. Continue at this point. We will try to stimulate further contraction. We will continue to see the patient on a weekly basis.

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