DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Lower extremity cellulitis and swelling.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who presented with complaint of lower extremity swelling and pain. He states he has had the swelling before; however, this is the first time he has developed this type of pain with this. He does not state that the swelling was any worse than it is typically. He states the swelling has insidiously increased over the past several years. He has also noticed some lower extremity skin changes as well. He states he has not had any known problems with his heart or lungs in the past.
PAST MEDICAL HISTORY: Hypertension which has been untreated, psychiatric illness including bipolar disorder, depression, and anxiety.
PAST SURGICAL HISTORY: Appendectomy.
CURRENT HOME MEDICATIONS: Celexa and Vistaril.
ALLERGIES: IV DYE.
SOCIAL HISTORY: He smokes one to two cigarettes per week. He drinks four or six beers per week.
REVIEW OF SYSTEMS: The patient denies any chest pain, palpitations, shortness of breath. No nausea, vomiting, diarrhea, constipation. No problems with fever or chills. No problems with GU or GI system.
PHYSICAL EXAMINATION:
GENERAL: This is a well-appearing, pleasant (XX)-year-old Hispanic male in no apparent distress.
VITAL SIGNS: Today are stable. He is afebrile. His temperature is 98.4, pulse 84, respirations 21, and blood pressure 124/80.
SKIN: Dermatologic evaluation reveals significant venous stasis skin changes of bilateral lower extremity. He has xerosis in the lower extremity bilaterally as well as the feet. His nails are thick, discolored, and hypertrophic consistent with fungal infection.
VASCULAR: Exam reveals significant pitting edema, +3, in bilateral lower extremities. Pulses are palpable but diminished. Lower extremities are warm from proximal to distal. No ascending cellulitis is noted at this time.
NEUROLOGIC: No focal deficit noted. Reflexes are +2/4 bilaterally and equal. Symmetrical patella, Achilles tendon. Epicritic sensation is intact, as is protective threshold.
EXTREMITIES: Pain on palpation of the bilateral lower extremities, left greater than right, mostly along the medial tibial area. This is most consistent with venous stasis-type pain.
LABORATORY DATA: WBC 7.4, H&H 13.2 and 39.8. PT is 13.6, INR 1.06, PTT 31.4. D-dimer elevated at 0.80. Sodium 141, potassium 3.2, chloride 108, CO2 of 24, BUN 9, and creatinine 0.9. Blood sugar today is 100; however, upon admission, it was around 155.
DIAGNOSTIC DATA: Venous Dopplers were performed and negative for deep venous thrombosis.
ASSESSMENT:
1. Venous stasis disease with possible mild overlying cellulitis.
2. Questionable diabetes mellitus. Hemoglobin A1c is pending. He did have elevated blood sugar upon admission.
3. Xerosis of lower extremities.
Given the significance of the venous stasis disease and pitting edema, the increased temperature in the lower extremities could be likely secondary to this versus cellulitis. However, we often see a mild cellulitis overlying this venous stasis-type disease.
RECOMMENDATIONS: We would continue with IV antibiotics at this time over the next several days. If the plan is to discharge him home, he can certainly be discharged on p.o. antibiotics. Recommend compression therapy and occupational therapy consult for lymphedema therapy. Also recommend TED hose and Jones compression stockings as outpatient. The patient was also admitted for outpatient lymphedema therapy. For the lower extremity xerosis, recommend Eucerin cream to apply twice daily; however, this is not an urgent problem and not causing any difficulty for him regarding this condition. If he does not have any resolution of systems over the next day or so, we would likely recommend lower extremity x-rays. We will see him every other day or so while he is in the hospital, otherwise, we can follow up with him as an outpatient.
Thank you for this consultation. Appreciate the opportunity to participate in the care of this patient. If you have any questions, please do not hesitate to contact me.
