Mr. Johnson has been concerned with a wound on his left lower leg that has not been healing well since he received it two weeks prior. Mr. Johnson scheduled a same day appointment with his primary care provider, Dr. Henson, DNP, FNP to have it evaluated. Upon arrival and check-in at Dr. Henson’s office, Mr. Johnson was taken back right away. His vitals were taken and were as follows:
DOB: 9/15/76
Height: 5’6
Weight: 260lbs
Temperature: 97.8
Heart rate: 88
Respirations: 16
Blood pressure: 151/76
O2: 98% on room air Image from: https://www.thesenior.com.au/story/
. 6246044/new-hope-for-chronic-leg-ulcer-sufferers/
The nurse, Pam, gathered more information about Mr. Johnson:
Medical Hx: Hypertension, obesity, wears glasses
Surgical Hx: None
Social Hx: Former smoker for 15 years, last tobacco use in 2009.
Family Hx: Hypertension- Father; Smoker- Mother; Grandparents- History unknown
Medications: Amlodipine 10mg PO daily
Mr. Johnson is taken to an exam room where Dr. Henson is waiting. Dr. Henson asks Mr. Johnson to provide details of the events leading up to the incident that caused the wound. Mr. Johnson states “I was cutting down some branches outside when one branch fell and cut me on my leg. I cleaned it with alcohol and wrapped it with a bandage I found in the house. I have been changing it every day but I noticed it is taking forever to heal. Do you think its because I’m getting old Doc? Today, I noticed it was a little more sore and redder than usual so I’m getting worried. I don’t know what the matter is.”
Upon examination of the wound, Dr. Henson noticed that the wound was erythematous, inflamed and appeared to be healing slowly. Dr. Henson is now suspecting an underlying cause and decided to ask Mr. Johnson if he has been having any weird or abnormal symptoms lately. Mr. Johnson replied, “I’m always thirsty, I drink like 10 bottles of water a day and I still feel thirsty. And I pee all the time, I mean ALL the time Doc. It’s ridiculous. I just don’t feel like myself. What does all that have to do with my leg though? Can’t I just get an antibiotic and go home? Um, do you happen to have a bottle of water I can drink right now?”