Case study on the use of ProT GOLD for wound healing on a 92-year-old female.
Warning: Contains Graphic Images
FACILITY:
Edward C. Cambell Junior Wound Care Center of Stephens County Hospital
ADMITTING PHYSICIAN:
Mark D. Herndon M.D.
ADMIT DATE:
October 4, 2018
CHIEF COMPLAINT:
Large skin injury to the left leg.
ASSESSMENT:
This is a 92-year-old female. Status/post-traumatic injury to left leg with partial closure and exposed muscle tissue.
PLAN:
1. The plan is to perform serial debridements and I have encouraged increased protein intake of protein (ProT GOLD) to assist with healing.
2. We will see her on a weekly basis until closed.
Image 1: Admission/Post-surgical wound
PROGRESS NOTE:
November 28, 2018 (55 Days Post Injury)
DICTATING PHYSICIAN:
Mark D Herndon, M.D.
ASSESSMENT:
This is a 92-year-old female, status/post laceration to the left leg, now healed.
Image 2: Post-treatment (ProT GOLD) wound image - 55 days after closure
PATIENT DETAILS:
AGE: 92
BIOLOGICAL GENDER:
Female
HISTORY OF PRESENT ILLNESS:
A 92-year-old female who is in remarkably good condition, but was recently on vacation in Tennesse. She attempted to climb into a golf cart, her shin hit the edge of the golf cart and did not tear her clothing, however, immediately blood began to pour from her left leg. She was taken to a nearby Emergency Room and was operated on to partially close the skin tear and defect. She was asked to follow up with a Wound Care Center specialist. She denies any significant changes. She denies any fevers or chills or systemic symptoms.
PAST MEDICAL HISTORY is significant for:
1. Hyperlipidemia
2. Obesity
3. Anemia of chronic renal failure
4. Macular degeneration
5. Hypertension
6. Congestive heart failure
7. Chronic kidney disease
8. Rosacea
POST-SURGICAL HISTORY:
1. Cholecystectomy
2. Hysterectomy
3. Thyroidectomy
MEDICATIONS at home:
1. Vitamin B12
2. Advair
3. Imdur
4. Levothyroxine
5. Nitroglycerine Patch
6. Simvastatin
ALLERGIES:
She is allergic to:
1. QUINAPRIL, presumably an ACE inhibitor
SOCIAL HISTORY:
Retired. Does not smoke or drink.
FAMILY HISTORY:
She does not describe her family history.
REVIEW OF SYSTEMS:
Is positive for some angina, edema of the lower extremities, some gout, and osteoarthritis but except as mentioned above,m a ten-system review of systems is negative.
LABORATORY DATA:
A culture of fluid pending.
DIAGNOSTIC STUDIES:
None.
PATIENT PROGRESS NOTE:
November 28, 2018
DICTATING PHYSICIAN:
Mark D Herndon, M.D.
ASSESSMENT:
This is a 92-year-old female, status/post laceration to the left leg, now healed.
SUBJECTIVE:
The patient feels that she is healed. She has no complaints of any pain in the left lower extremity where she had an injury.
OBJECTIVE:
VITAL SIGNS:
She is afebrile, vital signs are stable.
IN GENERAL:
She is well-developed, well-nourished, caucasian female in no apparent distress. She is alert and oriented times three.
HEAD: Is normocephalic
EYES: Are anicteric.
RESPIRATORY: Breathing is even and unlabored.
CARDIOVASCULAR: Heart is of regular rate and rhythm.
ABDOMEN: Is flat, soft, non-tender to palpation, no palpable masses.
EXTREMITIES: There is no edema or bilateral lower extremities. The large laceration to the anterior surface of her left leg is now completely epithelialized consistent with healing. It is non-tender to palpation.
LABORATORY DATA:
None.
DIAGNOSTIC STUDIES:
None.
ASSESSMENT:
This is a 92-year-old female, status/post laceration to the left leg, now healed.