Sarah Smith is a 28 y/o African American female who presents to the office with c/o wound to her left foot for the past few days. States she had tripped and fell while barefoot scraping the top of her foot on the pavement. She denies any other injury from the incident. Over the past 24 hours the wound has had “smelly” drainage. Has been experiencing generalized achiness, but denies fever and chills. Did not seek medical attention at the time of injury. Has been using hydrogen peroxide to clean her wound. Is unclear of her last tetanus vaccination. Patient PMHx significant for DM II. States that she takes her medications when she remembers, and does not always check her blood sugar.
Asthma: no hospitalizations for exacerbation.
Former tobacco user: ceased smoking 2 years ago. Had smoked 1ppd x 5 years
Illicit drugs: denies
Significant for paternal DM, otherwise unremarkable
Metformin: 500mg BID po – did not take the last few days
Albuterol MDI: 2 puffs every 6 hours prn – last use just PTA
Singulair: 10mg po daily
Trinessa: 1 tab po daily – last taken this am
LNMP: 2 weeks ago.
General: denies any weight changes, fatigue or fever; + body aches
Skin: denies any rashes; + wound to left foot
HEENT: denies headache, head injury, dizziness, lightheadedness;
Denies any vision changes
Denies any hearing changes, tinnitus, vertigo, earache
Denies any nasal congestion, discharge, nose bleeds or sinus tenderness
Denies any sore throat, difficulty swallowing
Neck: denies any swollen glands, pain
Breasts: denies any pain, discharge
Respiratory: denies any dyspnea; positive cough and wheezing
CV: denies any chest pain, edema
GI: denies any nausea/vomiting/diarrhea/constipation; denies bloody stools
PV: denies claudication, swelling to LE
GU: denies frequency, urgency, burning;
Denies vaginal discharge, itching, sores
Denies penile discharge, itching or sores
MS: positive pain to left foot
Psych: denies nervousness, depression
Neuro: denies Headache, dizziness, vertigo, syncope, weakness; + numbness to right LE
Heme: denies any easy bruising
Vital signs: 100.5 (tympanic), 162/88, 118, 22, O2 sat 95% on RA
Height: 5’5” Weight: 250 lbs.
Blood glucose: 230 (Fasting; states has not eaten yet today)
patient awake, alert, oriented x 4 in NAD
Skin: warm, dry, color WNL. 4 cm lesion noted to anterior left foot with crusting and purulent drng; + surrounding erythema extending up 7 cm proximally
HEENT: head nontraumatic, normocephalic
Pupils PERRLA, EOMs intact; disc margins sharp, without hemorrhages, exudates; no AV nicking noted
Ears: bilateral TM with good cone of light and intact
Nose: mucosa pink, septum midline; no sinus tenderness appreciated
Mouth: mucosa pink, moist; tongue midline; tonsils 1+ without exudate
Neck: supple; trachea midline; no LAD
Resp: regular and unlabored; lungs with end expiratory wheezing throughout
CV: RRR, S1 and S2 noted; no s3, s4 or murmur appreciated
Abdomen: soft, non-distended; Bs + x 4; no tenderness with palpation; no CVA tenderness with percussion
Extremities: warm and without edema; calves supple, non-tender
PV: no LE edema
MS: + swelling to left foot; + tenderness of 2-4th left metatarsals; + left pedal pulse; CMS intact; Cap refill < 2 sec.
Neuro: alert, cooperative; thought coherent; oriented x 4; cranial nerves II-XII intact
List your differentials for her current problems. Remember you should have at least three different differentials for each problem. Include rationale for each differential.
At this time what medical diagnoses are you most concerned about? Do they impact other diagnoses? If so, how?
What diagnostic images would you order? Provide your rationale. What are you trying to rule in or out?
What laboratory work would you order? What would you anticipate to be abnormal? Provide your rationale for each.
What is your comprehensive plan of care? Include your rationales.
Include 3-5 references with in-text citations. Must be within 5 years
Sarah Smith, a 28-year-old African American woman, has a c/o wound on her left foot. She stumbled and fell barefoot, scraping her foot on the pavement. She denies any other injuries. The wound has produced “smelly” drainage for 24 hours. Has widespread aches but no fever or chills. Didn’t seek medical attention when injured. Cleans her wound with hydrogen peroxide. Her last tetanus shot is unknown. Patient PMHx for DM II. She says she only takes her pills when she recalls and doesn’t always check her sugar.
No asthma exacerbations hospitalized.
Former smoker: quit 2 years ago. 1ppd for 5 years
Except for paternal DM, unimpressive
Metformin: 500mg BID po – missed a couple days
Albuterol MDI: 2 puffs every 6 hours prn
Singulair: 10 mg tid
Trish: 1 tab p.o.
2 weeks LNMP.
+ bodily aches; denies weight changes, weariness, or fever.
Skin: no rashes; + left foot wound
“Headache”: “Headache”: “Headache”:
Refutes any eye alterations
Denies hearing loss, tinnitus, vertigo, or ear pain.
Denial of sinusitis or nasal congestion.
Denies painful throat or swallowing issues
Neck: no swollen glands, no pain
Breasts: no pain, no discharge
Respiratory: no dyspnea, but coughing and wheezing
CV: no chest pain or edema
GI: denies nausea/vomiting/diarrhoea/constipation/bloody stools.
PV: no claudication, no edema LE
GU: denies recurrence, urgency, or
Denies discharge, irritation, and sores
Denial of penile discharge, itching, and sores
MS: left foot pain
Psych: denies anxiety, sadness
denies numbness to right LE, headache, dizziness, vertigo, syncope
Heme: no visible bruises
tympanic), 162/88, 118, 22, O2 sat 95% on RA
5’5″ 250 lbs
230 mg/dl (Fasting; states has not eaten yet today)
OAD x 4 in NAD
Lesion 4 cm in size, anterior left foot, crusting and purulent drng; surrounding erythema 7 cm proximally
HEENT: normocephalic, nontraumatic
There were no signs of AV nicking or hemorrhaging in the pupils.
Bilateral TM with nice light cone and intact
Nose: pink mucosa, midline septum; no sinus pain
Tonsils 1+ without exudate, pink mucosa, tongue midline
Thyroid: no LAD; trachea midline
End expiratory wheeze throughout the lungs
There was no s3, s4, or murmur.
Soft, non-distended abdomen; Bs + 4; no palpable CVA discomfort; no percussion tenderness
Extremities: warm, no edema; elastic, non-tender calves
No LE edema.
CMS intact; Cap refill 2 sec.
Oriented x 4; cerebral nerves II-XII intact
List your solutions to her present issues. Remember to have three differentials for each task. Justify each disparity.
What medical diagnoses worry you now? CAN THEY AFFECT DIFFER But how?
What tests would you order? Justify your choice. What are you seeking to exclude?
What tests would you order? What do you consider abnormal? Justify your choices.
What is your overall care plan? Include reasons.
Include 3-5 in-text citations. 5 years or less