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Patient Details : Mr. Will Jackson, a 77 years old man, diagnosed…

 

Patient Details             : Mr. Will Jackson, a 77 years old man, diagnosed with Rectal

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Cancer 5 years ago.

Presenting Problems: poor oral intake, intermittent pain from his wounds both from

diabetic foot ulcer & arterial ulcer

Past history                 : IHD, previous CABG (2 years ago), COPD, ETOH, GORD,

Postural hypotension & T2DM on insulin

Cognitive                     : intermittent confusion at times

Social                          : lives in retirement village alone. Wife passed away 1 year ago

Diet                              : poor oral intake for the last 2 weeks. Patient likes soft drinks

Continence                  : incontinent, pad in situ

Mobility                        : 2 GF (short distance), WC for long distance.

Medications                 : Telmisartan 40 mg. b.d, Ventolin 4 puffs t.d.s, Esomeprazole

20 mg daily, Lantus 20 units (mane), warfarin 2 mg (daily),

Frusemide 20 mg b.d. PRN: Endone 10mg t.d.s, Hydromorphone

2 mg (b.d)

 

Mr. Jackson was admitted to the ward for pain management, SOB & wound management. Prior to admission, he had a fall at home with a head strike and developed a bruise over his face. CT scan result: NAD. The doctor ceased his warfarin dose for a week due to this massive bruise.

Mr. Jackson has a diabetic foot ulcer behind his L) toe that requires debridement while in hospital.

He also has arterial ulcer on his R) lower leg which appears infected. The treating doctor ordered a wound swab to be taken and send to pathology. The result confirmed that it is infected.

Mr Jackson also has a pressure ulcer on his sacrum bone which was discovered when he first admitted into hospital post fall. It is a stage 3 pressure ulcer and causes him a lot of pain especially if he is lying in a supine position. Mr Jackson thought it was pain from his cancer in the rectum. The wound base of the ulcer consists of 70% sloughy tissue and 30% granulation tissue.

On day 3 in hospital, patient suffered from a burn because he spilled a hot coffee over his L) arm. He sustained a second degree burn because of this.

Picture 1: diabetic ulcer

 

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