Can some please help me? I'm not sure of the whole report. Thanks

Name: Terry McGill HISTORY AND PHYSICAL EXAMINATION
#050749
Dr. Sung Pak

HISTORY

CHIEF COMPLAINT: Chronic draining left forearm wound.

HISTORY OF PRESENT ILLNESS: The patient was involved in an altercation, about one and half years ago and sustained a stab wound to the proximal left forearm. The patient was seen in an emergency room and the wound was irrigated and closed at that time, but it never healed and began draining a small amount of ___________ discharge. The patient did not seek further medical attention until about six months ago when he was seen at our clinic and diagnosed with adult onset diabetes mellitus. A bone scan today revealed a positive technetium up-take in the ulna which probably indicates chronic osteomyelitis of the proximal ulna. The patient is being evaluated today for admission, for irrigation and drainage and curettage of the left ulna.

PAST MEDICAL HISTORY: Medications: Diabinese 5 mg p.o. q.d. Allergies: NONE. Social history: Alcohol, one to one and half bottles of port wine per day. Denies history of delirium tremens. Last drinking was yesterday. Tobacco, one pack per day x 30 years. Illnesses and Surgeries: Appendectomy age 12. Bilateral ulnar nerve decompression. Traumatic amputation of left hand index finger at the midphalanx. ___________ and the ring finger at the proximal phalanx. Middle finger at second phalanx.

REVIEW OS SYSTEMS: Except as noted in the HPI and the past medical history, noncontributory.

PHYSICAL EXAMINATION: General: The patient is a morbidly obese 45-year-old Caucasian male in no acute distress. Skin: Dry and warm. No intertriginous abnormalities are identified. HEENT: PERRLA. TMs intact. Mucosa pink and moist. Neck: Supple. Trachea midline. Thyroid not palpable. Chest: There is a gynecomastia present without masses. Lungs: Clear to percussion. Heart: No murmurs are heard. Regular rate and rhythm. Abdomen: There is a well-healed right lower quadrant scar present. The abdomen is protuberant. No masses are palpated. Examination is limited by patient’s morbid obesity. Bowel sounds are fully heard. Rectal and genitalia: Deferred. Extremities: Left upper extremity: There is a 1 cm squared dusty, dry S scar over the proximal ulna. No discharge from the wound is seen. There is minimal tenderness. There is no erythema, cellulites, streaking. There is full range of motion of the elbow with flexion and supination and pronation without pain. Grip in the upper extremities is 5/5 bilaterally. Pulses are equal bilaterally. Reflexes are equal bilaterally.

IMPRESSION
Status post stab wound to the left forearm with chronic draining of sinus, probably osteomyelitis of the proximal ulna.


CONTINUED
HISTORY AND PHYSICAL EXAMINATION Terry McGill
Page 2 #050749

PLAN: _______, curettage of bone, intravenous antibiotics, am fasting blood sugars and ________ postprandial blood sugars to monitor current diabetic therapy.

purulent discharge
* don't have the next blank...sorry

PLAN: I&D, curettage....2-hour postprandial blood sugars...

Hope that helps!

Also, we pretty much have the same thing. However, I am not quite sure if there is a hyphen in uptake. Might want to check on that.

Can some please help me? I'm not sure of the whole report. Thanks I will help this time b/c this is a self-grade quiz

Name: Terry McGill HISTORY AND PHYSICAL EXAMINATION
#050749
Dr. Sung Pak

HISTORY

CHIEF COMPLAINT: Chronic draining left forearm wound.

HISTORY OF PRESENT ILLNESS: The patient was involved in an altercation (Omit ,) about one and half 1-1/2 years ago and sustained a stab wound to the proximal left forearm. The patient was seen in an emergency room, and the wound was irrigated and closed at that time, but it never healed and began draining a small amount of purulent discharge. The patient did not seek further medical attention until about six months ago when he was seen at our clinic and diagnosed with adult-onset diabetes mellitus. A bone scan today revealed a positive technetium up-take uptake in the proximal ulna which probably indicates chronic osteomyelitis of the proximal ulna. The patient is being evaluated today for admission(Omit ,) for irrigation and drainage and curettage of the left ulna.

PAST MEDICAL HISTORY: Medications: Diabinese 5 mg p.o. q.d. daily. Allergies: NONE. Social history: Alcohol: one to one and half 1 to 1-1/2 bottles of port wine per day. Denies history of delirium tremens. Last drinking was yesterday. Tobacco: One pack per day x 30 years. Illnesses and Surgeries: Appendectomy, age 12. Bilateral ulnar nerve decompression. Traumatic amputation of left hand index finger at the midphalanx, long and the ring finger at the proximal phalanx, Middle little finger at second phalanx.

REVIEW OS SYSTEMS: Except as noted in the HPI and the past medical history, noncontributory.

PHYSICAL EXAMINATION: General: The patient is a morbidly obese 45-year-old Caucasian male in no acute distress. Skin: Dry and warm. No intertriginous abnormalities are identified. HEENT: PERRLA. TMs intact. Mucosa pink and moist. Neck: Supple. Trachea midline. Thyroid not palpable. Chest: There is a gynecomastia present without masses. Lungs: Clear to percussion. Heart: No murmurs are heard. Regular rate and rhythm. Abdomen: There is a well-healed right lower quadrant scar present. The abdomen is protuberant. No masses are palpated. Examination is limited by patient’s morbid obesity. Bowel sounds are fully poorly heard. Rectal: Deferred. and Genitalia: Deferred. Extremities: Left upper extremity: There is a 1 cm squared, dusty, dry S scar eschar over the proximal ulna. No discharge from the wound is seen. There is minimal tenderness. There is no erythema, cellulites, streaking. There is full range of motion of the elbow with flexion and supination and pronation without pain. Grip in the upper extremities is 5/5 bilaterally. Pulses are equal bilaterally. Reflexes are equal bilaterally.

IMPRESSION
Status post stab wound to the left forearm with chronic draining of sinus, probably osteomyelitis of the proximal ulna.


CONTINUED
HISTORY AND PHYSICAL EXAMINATION Terry McGill
Page 2 #050749

PLAN: I&D, curettage of bone, intravenous antibiotics, a.m. fasting blood sugars and 2-hour postprandial blood sugars to monitor current diabetic therapy.

long and ring finger at proximal phalanx,

Thank You guys, that helps a lot.

You're welcome.