HF Henry Ford Case Study

MEDICATIONS:

1.  Plaquenil 200 mg a day.

2.  CellCept (start date 2002) 500 mg b.i.d.

3.  Atacand 8 mg a day.

4.  Depakote 500 mg twice a day.

CHIEF COMPLAINT:   

Ulcer on the right ankle.

HISTORY OF PRESENT ILLNESS:  Dr. Moody reports that her son has had an ulcer in the area of his right Achilles tendon for the last 3 months.  The ulcer may have begun as a consequence of pressure from hardware that he requires to support his right ankle.  However, she reports that this hardware has been modified and supposedly the pressures have been reduced.  She applies a DuoDERM patch to the lesion every day.  On occasion, she uses topical antibiotics.

REVIEW OF SYSTEMS:  Patient has no cough, no abdominal pain.  No rashes.

PAST MEDICAL HISTORY:  Bilateral hamstring releases and bilateral lower or distal tibial derotation osteotomies in September of 2007.

PHYSICAL EXAMINATION:

VITAL SIGNS:  Weight is 121 pounds.  Blood pressure 129/76 with a pulse of 76 and temperature of 98.

HEART:  Heart tones okay.

MUSC/SK:  I found no evidence of arthritis involving the joints of the hands, wrists, elbows, knees, ankles, and feet.  No ulcers on the hard palate.  No cervical lymphadenopathy.

SKIN:  There was a circular ulcer 1 cm in diameter over the lateral aspect of the right ankle slightly to the right and above the insertion of the Achilles tendon.  Bed was clean.  Ulcer shallow.  Edges did not appear to be raised nor were they red.  No surrounding skin erythema.  Good dorsalis pedis pulse.

IMPRESSION:  Probable pressure ulcer, right ankle.

MEDICAL DECISION MAKING:  I made arrangement for the patient to be seen in the Dermatology Clinic today.  Prescription provided for CellCept and Plaquenil.  Laboratory tests requested.