CHIEF COMPLAINT: Blisters on feet.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old homeless female who states that last week she got her feet all wet and since then has had her feet sore in her wet shoes and socks. Now, she has blisters and peeling of the skin on her feet. She states they are very painful. She is ambulatory but it is very painful. She rates the pain as a 10/10 and exacerbated by walking. She tells me she does not want to take her shoes off because she is afraid someone will steal them on the street. She has not had fevers or chills. She does complain that she feels like it might be spreading to her palms as she scratched the foot the other day and now her palms are somewhat itchy, though there are no actual blisters there. She denies any other skin manifestation or loss of sensation to the feet.
REVIEW OF SYSTEMS: As above. Otherwise, negative.
PAST MEDICAL HISTORY: Significant for right arm surgery.
MEDICATIONS: Ibuprofen.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is homeless. She actually comes in by squad and is accompanied by her boyfriend who also comes in by squad.
PHYSICAL EXAMINATION:
VITAL SIGNS: On admission to the ER today, temperature 97.2, blood pressure 112/78, pulse 74, respiratory rate 18 and O2 saturation 98% on room air.
GENERAL: The patient is a (XX)-year-old thin Hispanic female who is disheveled in appearance, wearing dirty clothes, but she is breathing easily and is well appearing, and is pleasant and cooperative with the exam.
EXTREMITIES: Examination of the patient’s feet reveals finding consistent with trench foot. She has got the peeling of the skin on the plantar aspects of both feet, right greater than left, erythema to both feet, several macerated areas that are oozing a little serous fluid, particularly between the toes of each foot and a foul odor coming from both the feet. There is no lymphangitic streaking, erythema or edema extending up into the feet or legs. Her sensation is intact. Capillary refill is brisk and pulses are symmetric and intact to lower extremities. Examination of the patient’s palms shows that they are very dirty, but there is no evidence for blister or lesion to the palms of her hands.
Here in the ED, her nursing notes were reviewed. She was given 2 pills of Vicodin for her discomfort as well as 0.375 g of Zosyn IV here for any infection that may be building. Her feet were cleaned, dried and dressed in a bulky gauze dressing with separation of the toes of each of the feet. The patient does have crutches with her to allow her to get off of her feet somewhat. We did discuss with this patient the possibility for respite care at one of the shelters, but she refuses this. She states she has been there before and does not wish to go back and just wants us to treat her and let her go back to the street. Dr. John Doe has seen this patient and agrees with the following assessment and plan.
ASSESSMENT: Trench foot.
PLAN:
1. The patient will be discharged home. She is to keep the feet clean and dry.
2. She is to follow up with the clinic of her choice.
3. She is started on Keflex as well as Vicodin, dispensed 12, and she is to return for worsening symptoms, fever or other concerns.
DISPOSITION: Home in stable condition.
