1. No category

Report 1
Name: Sarah Eames
#030201
Dr Robert Snow
PLASTIC SURGERY CONSULTATION REPORT
REASON FOR REFERRAL
I was asked by Dr Jones to see this 30-year-old male for evaluation of cellulitis secondary to
burn injury.
1
HISTORY OF PRESENT ILLNESS
Several days ago the patient fell in the kitchen, injuring his right upper arm. When the patient
turned to look at his arm in the shower, he burned the posteromedial upper arm with hot water. In
spite of local treatment initiated after an emergency room visit, he developed increasing
cellulitis.
PAST HISTORY
Medications: No medications.
Illnesses: Denies history of diabetes.
ALLERGIES: NO KNOWN ALLERGIES.
REVIEW OF SYSTEMS
Noncontributory.
PHYSICAL EXAMINATION
GENERAL: The patient is afebrile. The right upper arm is swollen, erythematous and warm.
There is a 2nd- and 3rd-degree burn measuring 20 x 7 cm on the posteromedial upper arm. Onethird of the area had ruptured bullae, and the remainder is covered by a black eschar.
DATABASE
White blood cell count 20,200.
ASSESSMENT
There is 2nd- and 3rd-degree burn, right upper arm, with cellulitis.
RECOMMENDATIONS
Debride eschar. Continue Silvadene dressings t.i.d. Once the wound is clean and granulating, he
will require a split-thickness skin graft to expedite wound closure. Agree with IV antibiotics.
Thank you for allowing me to assist in the care of your patient.
__________________________________
2
Robert Snow, MD
D:
T:
RS:
Footnotes
1
Patient name is female. You could use either flag the gender discrepancy or notify the doctor to check the
discrepancy when the report is reviewed.
2
Edit to avoid starting the sentence with a numeral. (Burn classifications must be typed using numerals.)