Patient Name: Gerald Edwards
Hospital No.: 11058
Date of Admission: 07/15/2010
Date of Discharge: 07/20/2010
Consultations: Gary Shelton, DPM and Midori Okano, MD
Procedures: Complicated incision and drainage, right foot, on 07/17/2010.
Admitting Diagnosis: Known diabetes mellitus. Ulceration of right foot.
HISTORY: The patient is a 53-year-old black individual, who has had diabetes for at least six months, but thinks it has been longer than that. He has had a foot ulcer since January.
Physical exam at the time of admission is significant for his lower extremities where he had good dorsalis and posterior tibial pulses bilaterally. His left foot had no abrasions, lesions, sores or ulcers. His right foot showed obvious deformity from a previous break. He has an area located between his second and third metatarsal head that has clearly been an abscess that has broken through. He also has had a foot ulcer located on the instep of his right foot, full thickness. There is tracking to the broken foot ulcerated area and there is question of osteomyelitis in this area.
DIAGNOSTIC EXAMINATION: During this hospital stay white blood count was initially 16,800 then 12, 000 one day post op. H&H were normal. UA was essentially unremarkable. Electrolytes were fairly normal with a glycosylated hemoglobin of 8.6 measured. Thyroid panel was normal. Urine chemistries revealed a protein of 0.18, a microalbumin of 44, and a creatinine of 0.69. Creatinine clearance was estimated at 31.8 and sed rate was 79. Blood cultures were negative. Swabs of the abscessed area revealed many beta streptococci. X-rays revealed heart size normal, lung fields clear. Right foot showed no acute changes other than moderate soft tissue swelling around the right toe. Left foot revealed no acute bony abnormalities. An MRI of the feet revealed marked soft tissue abnormalities of...