Monday, April 25, 2016

Medical Plan for the patients

This is a male patient with a past medical history significant for atrial fib who presents with bilateral lower extremity edema and redness.

1. Bilateral lower leg cellulitis. Lower extremity Doppler negative. We will continue clindamycin. We will elevate lower extremities.

2. Dizziness, chronic. We will check orthostatic. We will consult PT and OT. We will continue cardiac monitoring.

3. DVT prophylaxis with Lovenox.

4. Code status is full code. The patient does not have a living will, power of attorney, or advanced directive. However, his surrogate decision maker is his step son, Joe Stallings. I have discussed the assessment and plan with the patient and he is agreeable to the current plan of care.