Report 2 Sarah Eames #SE030201CR - At
Transcription
Report 2 Sarah Eames #SE030201CR - At
Report 1 Name: Sarah Eames #030201 Dr Robert Snow PLASTIC SURGERY CONSULTATION REPORT REASON FOR REFERRAL I was asked by Dr Jones to see this 30-year-old male for evaluation of cellulitis secondary to burn injury. 1 HISTORY OF PRESENT ILLNESS Several days ago the patient fell in the kitchen, injuring his right upper arm. When the patient turned to look at his arm in the shower, he burned the posteromedial upper arm with hot water. In spite of local treatment initiated after an emergency room visit, he developed increasing cellulitis. PAST HISTORY Medications: No medications. Illnesses: Denies history of diabetes. ALLERGIES: NO KNOWN ALLERGIES. REVIEW OF SYSTEMS Noncontributory. PHYSICAL EXAMINATION GENERAL: The patient is afebrile. The right upper arm is swollen, erythematous and warm. There is a 2nd- and 3rd-degree burn measuring 20 x 7 cm on the posteromedial upper arm. Onethird of the area had ruptured bullae, and the remainder is covered by a black eschar. DATABASE White blood cell count 20,200. ASSESSMENT There is 2nd- and 3rd-degree burn, right upper arm, with cellulitis. RECOMMENDATIONS Debride eschar. Continue Silvadene dressings t.i.d. Once the wound is clean and granulating, he will require a split-thickness skin graft to expedite wound closure. Agree with IV antibiotics. Thank you for allowing me to assist in the care of your patient. __________________________________ 2 Robert Snow, MD D: T: RS: Footnotes 1 Patient name is female. You could use either flag the gender discrepancy or notify the doctor to check the discrepancy when the report is reviewed. 2 Edit to avoid starting the sentence with a numeral. (Burn classifications must be typed using numerals.)