SUBJECTIVE: This is a (XX)-year-old Hispanic female with a past medical history as mentioned in the previous visit, who came for a followup for the ulcers in the left leg. Apparently, the left ulcer has still not completely healed but with erythema and less induration. There is some purulent discharge noted. The leg edema is markedly improved with diuretics. The patient still has some engorged varicose veins but without any new ulcerations.
OBJECTIVE:
GENERAL APPEARANCE: The patient is a morbidly obese, fairly-developed female. The patient is alert and oriented x3, not in any acute distress. The patient is ambulatory.
VITAL SIGNS: Temperature 98.4 with a blood pressure of 132/80, pulse of 88, respirations of 20, and weight of 221 pounds, which is decreased from the previous weight of 228.
LUNGS: Clear to auscultation.
CARDIOVASCULAR SYSTEM: Normal rate. Regular rhythm. There is no gallop
EXTREMITIES: The extremities are still with about 1+ to +2 pitting leg edema and there is still an open leg ulcer on the left shin area, the mid section, but without any purulent discharge. No visible induration noted. Mild erythema. There is no active bleeding noted and nontender. The patient also has good pedal pulses.
NEUROLOGIC EXAMINATION: Intact.
ASSESSMENT AND PLAN:
1. Nonhealing ulcers of the left leg. Plan is to retreat with Cipro 500 mg p.o. b.i.d. for 10 days with clindamycin 300 mg p.o. 3 times a day for 10 days. Would get an x-ray of the left leg and also refer the patient to Infectious Disease for further evaluation and management as well as outpatient wound care center. The patient will be followed up in about a month.
2. Hypertension, well controlled. Will continue with the diuretic with Lasix 20 mg b.i.d. with potassium supplement.
3. Leg edema most likely secondary to venous insufficiency. Continue with the same treatment as #2.
4. The patient will be advised to follow up in about a month.
