Pickens County Medical Center, Inc.
241 Robert K. Wilson Drive
Carrollton, AL 35447
205-367-8111
Discharge Summary
4/30/2002...5/3/2002
5/1/2002:
Mr. XXXXXX says that he is feeling better today. Reports from the nursing staff and his wife indicate that he is back to his mental baseline. He has still been having some episodes of hypoglycemia and today and large right heel ulcer was discovered that was most likely what is causing his blood sugar problems at this point. He has been requiring D50 about every 2 hours to keep his blood sugar up but he has no other complaints today. He says however, that he is a bit short of breath still but it has improved a bit from yesterday. No other complaints of pain at this time. Dr. XXXXXX has been consulted and he will be debriding his heel wound in the morning. Will send some cultures today to see if we can identify any organisms. He has been placed on Timentin and Cipro empirically thus far which I totally agree with.
HEENT: Benign.
NECK: Supple without JVD or excessive swelling.
LUNGS: There are some rales in both bases. No significantly increased work of breathing. There is some coarse breath sounds in the upper fields probably due to upper airway congestion.
HEART: Irregularly irregular with controlled rate.
ABDOMEN: Benign.
EXTREMITIES: The right heel has a large 3.5 cm decubitus ulcer with a couple of areas that appear to be oozing some purulent material. He has had trouble with peripheral vascular disease in this area and has several digits amputated on both feet.
DATABASE: WBC 7,200. HGB 12.1. HCT 35.3. PLT 181,000. Glucose 210. BUN 17. Creatinine 1.2. Sodium 125. Potassium 3.8. Chloride 93. CO2 21. Calcium 7.5. CPK 81. Cardiac Enzymes are negative.
IMPRESSION:
1. Confusion/hypoglycemia.
2. Right heel decubitus ulcer.
3. Status post recent carotid stinting procedure at UAB.
PLAN: He will go to the OR for debridement of his right heel wound. Will continue close observation of his blood sugar and give D 50 when necessary. Will change him to a full liquid diet with some chicken broth tonight as he has requested. I will give him 40 mgs of IV Lasix now and reassess him with some lab work tomorrow morning. I will see him after he gets done in the OR.
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5/2/2002:
Mr. XXXXXX underwent debridement of both heels today by Dr. XXXXXX. The procedure went well. Mr. XXXXXXX seemed to tolerate it very well. He has remained afebrile overnight and blood sugar has been stable. He has been eating well and denies any new problems today. He has been hemodynamically stable without any shortness of breath. He says he had a little bit of a cough but he thinks this is left over from a cold that he caught shortly after being discharged from UAB. He is not having any pain in his chest. His I's and O's yesterday showed him to be about 1 liter positive so will cut his IV rate down today to try to limit the amount of IV fluids that he is getting. He is having a decent response to the Bumex so will keep supplementing with extra doses as needed.
LUNGS: Clear with slightly decreased breath sounds bilaterally. No increased work of breathing. A little bit of upper airway congestion is present.
HEART: Regular with frequent ectopy.
ABDOMEN: Soft. Nontender. Nondistended. Normal bowel sounds without masses.
EXTREMITIES: 1 to 2 + pitting edema up to the knees. The feet are bandaged bilaterally. There is a little bit of blood drainage, but this is to be expected since he is fresh out of the procedure.
DATABASE: WBC 8,100. HGB 11,7, HCT 34.3 PLT 172,000. Glucose 90. BUN 17. Creatinine 1.1. Sodium 126. Potassium 4.3. Chloride 92. CO2 24. Calcium 7.7. INR 5.04.
IMPRESSION:
1. Status post debridement of both heels for gangrenous changes.
2. Recent hypoglycemia, resolving.
3. Recent confusion, also resolving.
4. Peripheral edema/CHF. Improving.
5. Hyponatremia.
6. Coumadin toxicity with elevated INR.
PLAN: Today will continue to supplement Bumex as necessary. Dr. XXXXXXXX has left instructions for the post op care of his foot wounds bilaterally. Will continue to keep a close eye on his blood sugars and cut his IV rate down to KVO. Will continue to follow his I's and O's closely. Will repeat some lab work and continue to hold his Coumadin in the morning in hopes that will see some improvement in his INR. I don't think there is any need to give Vitamin K at this time. No other changes for now. Will reassess things tomorrow morning.
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5/3/2002:
Will DC Glipizide and change Glucophage to 850 mg po q day. Resume home Coumadin dose, resume Cipro at home dose, and change Bumex to 1 gram po tid.
DISCHARGE DIAGNOSES:
1. Gangrene right heel and left fore foot.
2. Hypoglycemia.
3. Confusion.
4. NIDDM.
5. Carotid disease.
FOLLOW APPOINTMENTS: Office appointment with Dr. Sheppard next Tuesday
DIET AT DISCHARGE: Unchanged.
DISCHARGE PLANS: Home Health will be following Mr. XXXXXXX while he is at home and keeping in touch with Dr. XXXXXX regarding dressing changes. Will not make any other changes other then those mentioned above. The family will contact us or Dr. XXXXXXXX if there are any problems over the weekend and will address those as they come up..