History of Present Illness:
Pt is a
who has developed pressure ulcer located at
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Past Medical History
Social History - reviewed
Home Medication - Reviewed
Allergies - Reivewed
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REVIEW OF SYSTEMS:
GENERAL: No malaise. No weight loss.
HEENT: No CO headache.
Eyes: No CO decreased or blurred vision.
Ears: No CO decreased hearing.
Nose: No bleeding.
Throat: No sore throat. No mass or mass noted
LUNGS: No shortness of breath. No cough. No difficulty with breathing
CARDIAC: No chest pain. No palpitations. chest heaviness. No arm or leg swelling or edema
GI: no co, no pain, bloating, or distension
GU: No frequency. No hesitancy. No blood in the urine, no burning on urination
NEUROLOGIC: No dizziness. No neuropathy. No headache.
MUSCULOSKELETAL: No neck pain or lower back pain.
Skin/Integuments - reported pressure wound
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Vitals:
Reviewed
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Labs:
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Physical Examination
GA: comfortable, no distress
HEENT: Atraumatic; normo-cephalic;
Eyes: EOMI, PERRLA
Nose: Nares patent, no sign of bleeding
Throat: Mouth is clear and no adenopathy, no deviation
NECK: Supple, no adenopathy, and no thyromegaly
LUNGS: No rhonchi, no wheezing. Displays no work of breathing
CHEST: Symmetrical excursion
CARDIAC: Regular, rate, & rhythm
ABDOMEN: soft, no pain, no distension, no peritonitis
EXTREMITIES: No cyanosis, No clubbing, No edema
The Wound --------------------------
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Imaging:
I have personally reviewed the imaging studies
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Labs:
I have personally reviewed the lab results
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Assessments, Diagnosis and Plans:
The patient is a
who has developed pressure necrosis of the ______________
Discussed with pt and or POA regarding treatment which include
surgical debridement vs alternatives.
For surgery,
The Risks and benefits of surgery were discussed with patient, which includes,
but are not limited to, postoperative or chronic pain, bleeding, wound infection,
hematoma, injury to other organs, or need for further procedures or workup.
Other Complications may include deep vein thrombosis(blood clots), as well as other side effects affecting
other organ systems such as the heart or lungs, and in rare circumstances, death as a result of the above complications.
Also, the wound will likely need to be left open for open dressing changes or VAC therapy
Depending on the wound status, stage debridement may have to be performed as well.
The patient understand and agrees to proceed with the proposed procedure.