Thank you Judy, much appreciated. i do have this benchmark 3-1 to complete. certain words just cannot make out from dictation. can you help?
DISCHARGE SUMMARY
DIAGNOSIS
1. Diabetic toe ulcer with peripheral vascular disease.
2. Type 2 diabetes mellitus.
3. Chronic renal failure.
4. Hypertension.
5. Hyperlipidemia.
HISTORY
The patient is a 71-year-old white male who presented to the hospital with cellulitis and toe ulcer with questionable osteomyelitis. He had noted progressive redness and swelling of the left first toe over the prior 3 days.
PAST MEDICAL HISTORY
Significant for type 2 diabetes mellitus complicated by peripheral neuropathy and chronic renal insufficiency, hypertension, and history of secondary hyperparathyroidism _________, peripheral vascular disease status post right leg bypass surgery, hyperlipidemia, and gallstones.
PHYSICAL EXAMINATION
Physical examination reveals a left first toe cellulitis with superficial ulceration. He was admitted for IV antibiotic therapy. Had x-ray studies, which did not reveal any evidence for osteomyelitis. Did have a _________ creatinine from his baseline of about high 2 range up to 4.1 treated with IV therapy, and seen by renal service because of his worsening chronic renal insufficiency. Angiography was not done as the MRI was unhelpful. They had suggested an angiography but because of the renal insufficiency, this was not able to be performed. His renal function did improve near back to baseline and the plan for him was to be discharged home and follow up for vascular surgery next week. Once his creatinine is stable, they will likely do a CO2/______ angiography as an outpatient to determine the need for any sort of interventional surgery on the left leg.
MEDICATIONS
At the time of discharge include Lantus 10 units h.s., Actos 45 mg daily, Trental 400 mg q.i.d., Acutrim 325 mg daily, _________ 12.5 mg b.i.d., Florinef 0.1 mg daily, simvastatin 20 mg daily in place of his usual Lipitor 10 mg daily, __________, Procardia XL 60 mg daily which has been increased during his hospitalization, Rocaltrol 0.25 mcg daily, Augmentin 500 mg b.i.d. for 5 additional days.
Edited by boardalong (02/07/12 01:38 AM)