care plan sample patient 1 b g
CHIEF COMPLAINT: draining left thigh wound
HISTORY OF PRESENT ILLNESS: patient sustained a gunshot wound to left
thigh in 1992. plate became loose likely secondary to infection in 1999. he
was treated with antibiotics and the wound allowed to heal by secondary
intention. wound intermittently underwent breakdown and drainage in 2014
following stress put on leg when patient stood for long hours. Plastic surgeon
didi a culture and found it was infected and erecommended a debridement which
was done July 15. He was discharged on pain killers and antibiotics. ID saw
patient in August 2016 per his Plastic surgery’s recs and determined that
stronger IV antibiotics would be required.
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