4. SOAP: follow up post op, cellulitis, diabetes

Follow up post hospital discharge: cellulites, diabetes
TG is a 67-year-old Caucasian female, married, with four adult
children. She has a history of obesity, hypertension and cellulitis in
both legs on different occasions. She was recently hospitalized for a
right leg cellulitis, treated with antibiotics and discharged from the
hospital. (She had been hospitalized previously also for right lower
extremity cellulitis.) During this hospitalization she was diagnosed
with new-onset diabetes. Fasting blood sugar 132. Glucose tolerance
test done in the hospital showed blood sugars to be 137 fasting, 1
hour BS 246, 2 hour BS 205. She was followed by a home care RN
after discharged from the hospital for the cellulitis and diabetes. She
was started on an 1800-calorie diabetic diet and has been monitoring
her blood sugars at home tid. TH is here for a follow-up posthospitalization visit.
S: 1. Cellulitis.
TG states that the cellulitis has improved. She has no further
drainage. She stated that the area on the back of her right calf has
dried up. She denies any pain, fever or chills. She has no difficulty
walking. She has been keeping her right calf wrapped with an ace
wrap, kerlix and ABD. She was given support stockings TEDs to wear,
but states that the ace wrap, Kerlix, and ABD dressing protect her leg
better if she were to bump it than the TED hose. She states that she
has been keeping her legs elevated when she isn’t walking.
She shares that after she had finished IV antibiotics she started on
Cephalexin PO at home and developed a rash and swollen tongue with
Cephalexin. She went to Urgent Care and was treated for an allergic
reaction and put on Cipro instead. She tolerated Cipro.
She was to start on a prophylactic antibiotic Penicillin V-K for six
months after she had finished the course of Cipro. Her last dose of
Cipro just finished yesterday.
CC: #2 Diabetes.
TG stated her blood sugars have been ranging 70-120. She brought
her booklet with her glucometer and her BS has been averaging in low
100s. She states she has been very scrupulous about following her
diabetic diet. She was given a booklet on portions and food groups.
She says she has lost 20 lbs over the past few months. She stated
she was trying to cut back prior to being diagnosed wit diabetes. She
states that it hasn’t been hard to follow the diabetic diet and that she
is actually enjoying eating a healthier diet.
O: Wt. today 288 lbs, last wt. 297. Ht 5’5”, BP 136-82
1. Right calf is dusky-purple in color. There is no erythema. Skin
intact without open areas or drainage. Skin is very dry with white,
flakey peeling skin over surface. There is 1-2 + non-pitting edema at
ankle. Dorsalis pedis pulses 1+ bilaterally. Feet are warm.
Circumference of calf appears equal in size to the left. Negative
Homan’s bilaterally.
HCTZ 25 mg QD
Zestril 5 mg QD
Atenolol 50 mg QD