SOAP:
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 post-hospitalization 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.
Medications:
HCTZ 25 mg QD
Zestril 5 mg QD
Atenolol 50 mg QD