Skin – Burn | CLINIBORG

HISTORY: provided by patient SO/family member present during visit chaperon/MA present during visit interpretation provided by family member/SO interpretation provided by MA complete history unobtainable d/t poor effort/affect complete history unobtainable d/t cognitive changes or lack of knowledge complete history unobtainable d/t language skills

CC: burn

LOCATION: left right upper lower proximal distal lateral medical dorsal ventral first second third fourth fifth middle

QUALITY: red blister denuded oozing

STATED CAUSE: immersion hot water cigarette sun contact with hot surface high voltage chemical

HPI: happened prior to arrival happened today happened yesterday happened days ago washed with water and covered with dressing taking OTC, not helping

RECENT HISTORY:

[+] reported [-] not reported
PCP visit ER/UC visit hospitalization travel ID exposure surgery/procedure
TETANUS: up to date less than five years ago 5-10 years ago greater than 10 years ago unknown
PMSH: reviewed, non-contributory diabetes immunosuppression fume exposure

REVIEW OF SYSTEMS: negative except as stated in HPI
General:

HEENT:

CV:

Pulmonary:

GI:

GU:

MSK:

Neurologic:

Psychiatric:

Endocrine:

Hematologic/lymphatic:

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General: well-appearing normal built heavy built muscular lean well-nourished emaciated frail no signs of discomfort visible while sitting in chair no signs of discomfort visible while ambulating and getting on/off exam table ill-appearing tired-looking short of breath diaphoretic good hygiene disheveled bizarre clothes body odor drowsy appears impaired slumped no ambulation aids/DME ambulation requires walker ambulation requires cane ambulation requires wheelchair wearing cervical collar wearing lumbar support wearing extremity brace

Head/Face: normocephalic, atraumatic symmetrical face CN grossly intact plethoric face alopecia facial droop

Eyes: clear conjunctiva w/o exudates or hemorrhage, anicteric sclera, EOM intact without nystagmus visual acuity grossly intact cornea clear glasses contacts conjunctival injection epiphora conjunctival exudate allergic shiners dysconjugate gaze

Ears: symmetrical and intact auricles bilaterally hearing to conversation intact clear canals without erythema or discharge TMs normal in appearance

Nose: nares patent bilaterally septum midline no facial tenderness mucosa pink and moist swollen and boggy mucosa mucosal congestion clear discharge yellow discharge crusty discharge rhinophyma

Mouth/Troat: normal voice, no stridor tongue normal in appearance w/o lesions and with good symmetrical movements moist oral mucosa without lesions patent pharynx w/o swelling or exudates uvula midline upper denture lower denture poor dentition oral ulcers gum swelling tooth decay hoarseness vesicles on soft palate petechiae on soft palate pharyngeal erythema w/o exudates

Neck: symmetric with free painless ROM and no masses supple no LAD no bruit or JVD anterior LAD posterior LAD thyroid enlargement nuchal tenderness

Chest/Lungs: normal work of breathing, symmetrical chest expansion clear and equal breath sounds bilaterally chest wall atraumatic and non-tender no axillary or supraclavicular LAD SOB decreased bilaterally wheezing crackles

CV: regular rhythm no murmurs no ankle edema pedal skin warm with good and equal pulses tachycardia irregular heart rhythm systolic murmur calf tenderness ankle edema varicosities stasis discoloration

Abdomen: normal visual inspection, no distension normal active bowel sounds soft non-tender no bruit auscultated over AA and renal arteries protruding surgical scar umbilical hernia diffuse tenderness over entire abdomen w/o RRG hypoactive bowel sounds hyperactive bowel sounds direct non-rebound tenderness colostomy in situ deferred

GU: no suprapubic tenderness no CVAT bilaterally Foley in situ normal external genitalia no inguinal LAD testicular tenderness urethral discharge verrucous papules vesicles crusted lesions deferred

MSK: no gross deformities, moves all extremities with good ROM for age full weight-bearing normal curvature and ROM in C- and L-spine for patient age strength, tone, and bulk symmetrical and grossly intact non-tender C-spine with good ROM paraspinal muscle spasm C-spine tenderness and DROM neck pain with active motion paracervical muscle spasm old surgical scar in C-spine trapezius tenderness kyphosis non-tender L-spine with good ROM paraspinal muscle spasm L-spine tenderness reduced painful ROM in lumbar region trigger points in L-spine old surgical scar in L-spine heel-walk and toe-walk without difficulty negative seated SLR positive seated SLR

Neuro: normal concentration and attention memory grossly intact balance and coordination grossly intact ambulates w/o limp or alteration in gait extremities strong w/o atrophy no gross motor deficits sensation symmetrical and grossly intact no involuntary movements or tremor antalgic gait wide gait shuffling gait diffuse numbness w/o dermatomal pattern dystonia tardive dyskinesia tics

Speech/Vocalization: normal for age clear and coherent slurred mumbling to self monotonous stuttering hypoverbal hyperverbal shouting high pitched loud soft slow rapid pressured groaning sighing crying perseveration flight of ideas repetitive questions self-depreciating statements repetitive statements of impending doom repetitive non-health related/financial concerns personal safety concerns suicidal ideation/threats requesting particular medication, test, referral, or accommodation raising voice defensive argumentative cursing, swearing providers/staff criticisms verbal threats sexual remarks racist remarks

Behavior/Psychomotor Activity: calm, pleasant, respectful cooperative with history and exam engaged good eye contact guarded anxious irritable frustrated labile agitated hostile forceful threatening gestures aggressive posturing pacing not sitting down fidgeting picking skin twirling hair cracking knuckles frequent hand gestures grimacing, frowning tightening jaw breathing hard fist-clenching intense staring subdued withdrawn constricted affect bradykinetic indifferent appears to be responding to internal psychotic process

Burn: single multiple does not cross joint non-circumferential erythema blister desquamation weeping/oozing epidermal partial thickness no ssx infection crosses joint circumferential ssx infection less than 5 percent TBSA 5-10 percent TBSA more than 10 percent TBSA

Refer out burns to face, eyes, ears, genitalia, joints, or from abuse, or smoke inhalation

DISCUSSION:

PLAN OF CARE: POC risks/benefits/alternatives discussed with patient/parent/SO, opportunity provided to ask questions verbalized understanding of and agreement with POC, discharge and f/u instructions did not agree with my POC/recommendations – will seek second opinion/further care elsewhere

PROCEDURE: area cleansed with NS debris removed area dried with gauze triple abx applied Bacitracin applied area covered with Xeroform dsg area covered with non-adherent dsg gauze dsg applied on top wrapped with Kerlix tetanus vac per clinic policy

RX: none electronic paper given to staff to be transmitted to pharmacy

REVIEWED: MA notes med list previous visits/results hospital discharge

COORDINATION OF CARE

VERBALLY INSTRUCTED ON: vital signs,exam findings, recommendations reporting medication side effects to clinic immediately appropriate follow up with specialist/burn center using hydrogel or Xeroform dsg for wound care changing dsg whenever soaked at least daily applying non-perfumed moisturizing cream (Vaseline Intensive Care®, Eucerin®, Nivea®, mineral oil, or cocoa butter) once epithelialization occurs; avoiding preparations high in lanolin elevating extremity to prevent swelling

BARRIERS TO CARE: language barrier socio-cultural factors poor effort/cooperation with exam incomplete history history not supported by findings vague complaints supporting documentation unavailable failed to obtain old records failed to complete referrals or testing multiple comorbidities polypharmacy multiple providers/prescribers intolerance of/allergty to/therapeutic failure on multiple meds frequent ER/UC visits frequent office contacts poor compliance with POC negative attitude to proposed tx lack of interest in non-drug tx overreliance on short-acting meds overwhelming focus on Rx drugs poor insight lack of motivation dependent attitude preoccupation with illness unhealthy coping mechanisms somatization catastrophization pessimism overgeneralization unrealistic health beliefs psych comorbidity anxiety depression alcohol or substance use social or occupational dysfunction secondary gain hostile/disruptive behavior affect none noted at this time

DISPOSITION: RTC as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or NVT compromise RTC 24 hours RTC 48 to 72 hours RTC 1 week referred to burn center for further management referred to ER for immediate treatment via 911 referred to ER for immediate treatment via private transport declined emergency transfer left facility before being discharged asked to leave clinic

Skin – Burn

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