Name: ………………………………………………….….……..

DOB: ………………………………. Gender: …………….

MRN: …………………………….. NOG: …………………
Adm. Date: …………………… Bed: …………….......
Physician: …………………………………………………..….
Coverage: ……………………………………………………...
Attending Admission Note
DATE: Thursday, September 17, 2020 TIME: 15:32 a9/p9
rd
CHIEF COMPLAINT: Black Left 3 toe
HISTORY: Case of 81 years old lady known to have DM2, DL, HTN,IDA, PVD s/p Right 5 toes amputation +
femoral popliteal bypass, right big toe amputation , presented with above chief complaint.
History goes back to 2 weeks ago when the patient started noting erythema of her 3 rd and 4th toes that started
to turn black 3 days ptp. The patient denies any fever or chills, night sweats, no cough , no rhinorrhea, no
dyspnea , no headache, no abdominal pain , no diarrhea, no dysuria, no other complaint.
Travel history: Negative
PMH: DM2
DL
HTN
IDA
PVD
PSH: Right Femoro-popliteal bypass + right toes amputation
Left big toe amputation
Allergies: none
Medications: Nexium 20mg OD
Eurofer CF 1 tab OD
Lercadip 10 mg 1 tab QPM
Concor 2.5 mg Bid
Plavix 75 mg OD
Glucophage 1000mg 2 tabs OD
Tresiba 24 units QPM
Micardis 80mg QAM
Hemax 10000 Unitssc MWF
SH: Non smoker , non alcoholic
ROS:
Constitutional: Denies fever, chills, weight loss or weakness
HENT:  Denies sore throat or ear pain
Respiratory: Denies cough or shortness of breath
Cardiovascular: Denies chest pain, palpitations or swelling
GI: Denies abdominal pain, nausea, vomiting, or diarrhea. Denies melena, hematochezia
GU:  Denies dysuria, polyuria, hematuria, flank pain
Neurologic: Denies headache, focal weakness or sensory changes

TEMPERATURE: 36.8 SPO2: 99% PULSE: 79 BP:138/66 HGT:99 WEIGHT: 60

GENERAL APPEARANCE: Normal, not in distress

NEURO: Alert & oriented x 3, normal motor function, normal sensory function, no focal deficits noted.
HEENT/NECK: Norm cephalic, atraumatic, oropharynx moist, no oral exudates, Nose normal. Neck- normal range of motion
LUNGS/HEART: Normal heart rate, normal rhythm, Systolic murmur, no rubs, no gallops. GBAE, no added sounds
ABDOMEN: Bowel sounds normal, Soft, no tenderness, no masses, no pulsatile masses.
GENITO-URINARY: No CVA tenderness
SKIN: Warm, dry, no erythema, no rash
OTHERS:Weak peripheral pulses
Bilateral trace pitting edema
Left 3rd toe black well demarcated , necrotic + 4th toes proximally necrotic with surrounding erythema

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MR F-10 Ed.7
 Name: ………………………………………………….….……..
DOB: ………………………………. Gender: …………….
MRN: …………………………….. NOG: …………………
Attending Admission Note (Continued)
Adm. Date: …………………… Bed: …………….......
Physician: …………………………………………………..….
DIAGNOSTIC TESTS: Coverage: ……………………………………………………...
WBC 19.89
RBC 3.33
HGB 9.5 SODIUM 140
HCT 29.9 POTASSIUM 5.6
MCV 89.9 CHLORIDE 103
MCH 28.7 CO2 23
MCHC 31.9 MAGNESIUM 1.6
CHCM 30.7 UREA 65
RDW 26 CREATININE 0.64
HDW 3.84
PLT 442
MPV 8.3
%NEUT 86
INR 1.18
PTT 28
CALCIUM 10.3
PHOSPHORUS 4.3
GGT 6
ALKALINE
65
PHOSPHATASE
SGPT 11
SGOT 13
C REACTIVE
< 0.5
PROTEIN (CRP)

IMPRESSION: : Case of 81 years old lady known to have DM2, DL, HTN,IDA, PVD presenting with left necrotic 3 rd toe
with high WBC:
R/o Cellulites
R/o Gangrenous toe
R/o Osteomyelitis

MANAGEMENT PLAN: IV Hydration

Start low act rapid scale + Tresiba 24u sc QPM
DVT Prophylaxis
CS Ortho (DrK. Yammine) : Follow up MRI Foot r/o osteomyelitis
Do US Doppler arterial + venous bilateral
Plan for amputation
CS ID : possible underlying cellulits , Follow up wound culture + Start Tazo 4.5g q6h
CS Hemato (Dr Rita Assi) : Follow up on anemia
Hyperkalemia : Give kyaxelate + Duphalac
Follow up CBCD , Chem 6 tomorrow

RESIDENT NAME & SIGNATURE: Ali Dakroub PGY1 DATE 9/17/2020 TIME:15:32 a9/p9

ATTENDING NAME & SIGNATURE: DATE TIME

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