DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Foot ulcer.
SUBJECTIVE: The patient presents today with a chronic ulcer to the right foot at the previous site of right second toe amputation. Her wound has failed to heal whether it has been left open for debridement or abscess drainage or whether it has been closed after resection procedures.
The patient has had a chronic osteomyelitis of this foot. She reports she has drainage at the site intermittently, and at times, when she has worsening infection, she has worsening pain in the foot. She has failed to stop smoking. She still smokes a pack and a half a day.
She was seen by Dr. John Doe and cleared to proceed with surgery. Right leg ankle-brachial index was 0.92 and the toe brachial index was 0.68. She was found to have biphasic flow in the tibioperoneal trunk and triphasic flow in the popliteal, anterior tibial, and posterior tibial on the right leg with triphasic flow throughout the left leg.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 37.4, pulse 104, respirations 18, and BP 132/74.
EXTREMITIES: The right foot has a 1.5 x 0.6 x 0.8 cm open wound that is still tracking down towards the bone of the second metatarsal and now she has developed an ulcer on the medial aspect of the right third toe, 0.4 x 0.5 x 0.3 cm.
ASSESSMENT: Chronic osteomyelitis of the right foot.
PLAN: The patient initially was going to have surgery but decided to wait, but is now back on surgery for a right transmetatarsal amputation. Risks and benefits have been discussed with her, including bleeding, infection, open wounds, and nonhealing. She demonstrates good understanding and wished to proceed.
The patient was given a new prescription for ampicillin 500 mg 4 times a day x2 weeks with one more refill. She will follow up for re-evaluation in the Wound Center in 3 weeks just prior to the proposed operation, and she again is strongly encouraged to stop smoking.
