Gerald Edwards Discharge Summary
HILLCREST MEDICAL CENTER
DISCHARGE SUMMARY
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.
Complications: None
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 …show more content…
The patient was placed initially on a sliding scale of insulin. The patient underwent incision and drainage of his right foot on July 17, had no complications and tolerated surgery well. One day post-op the patient spiked a temperature to 101 degrees Fahrenheit. The patient was placed on Unasyn. He defervesced quickly. At the time of discharge his vital signs were stable. He was afebrile. His antibiotics were changed to Augmentin and he was discharged to his daughter’s home.
DISPOISTION: The patient was discharged three days post-op in good condition on Augmentin 500 mg p.o.q. 8h. And insulin on a sliding scale.
FOLLOW UP: The patient is to be followed by Dr. Shelton in his office, first available appointment and by Dr. Okano’s office in six months. To call his doctor or come back to Hillcrest ER for any signs of wound infection, fever, pain or bleeding.
DISCHARGE DIAGNOSES
1. Diabetes mellitus, insulin dependent.
2. Diabetic neuropathy.
3. Chronic ulcer of the right
DISCHARGE SUMMARY
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.
Complications: None
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 …show more content…
The patient was placed initially on a sliding scale of insulin. The patient underwent incision and drainage of his right foot on July 17, had no complications and tolerated surgery well. One day post-op the patient spiked a temperature to 101 degrees Fahrenheit. The patient was placed on Unasyn. He defervesced quickly. At the time of discharge his vital signs were stable. He was afebrile. His antibiotics were changed to Augmentin and he was discharged to his daughter’s home.
DISPOISTION: The patient was discharged three days post-op in good condition on Augmentin 500 mg p.o.q. 8h. And insulin on a sliding scale.
FOLLOW UP: The patient is to be followed by Dr. Shelton in his office, first available appointment and by Dr. Okano’s office in six months. To call his doctor or come back to Hillcrest ER for any signs of wound infection, fever, pain or bleeding.
DISCHARGE DIAGNOSES
1. Diabetes mellitus, insulin dependent.
2. Diabetic neuropathy.
3. Chronic ulcer of the right