</REASON FOR ADMISSION/>

Continued wound care.

</HISTORY OF PRESENT ILLNESS/>

Ms. Bellestri is a pleasant 63-year-old white female who was admitted to Regency Hospital of
Toledo from St. Vincent Mercy Medical Center where she has been cared for by Dr. Clark for right
lower extremity above-knee amputation stump infection. Apparently, she had above-knee
amputation earlier this year. Had done well, and 5 days prior to her admission at St. Vincent's,
she started developing increasing pain, some swelling of the stump, and was evaluated by Dr.
Clark. Patient was directly admitted to the hospital. She underwent drainage of infection. She
was seen by Infectious Disease at ______ Hospital and ultimately had done well. She was
admitted to Regency Hospital at this time. She continued to see wound care, continued IV
antibiotics and supportive care. She was currently seen in her room. She denied any chest pain,
shortness of breath, nausea, vomiting, or other complaints.

</PAST MEDICAL HISTORY/>

Significant for peripheral arterial disease, diabetes mellitus type 2, hypothyroidism, coronary
artery disease, hypertension, dyslipidemia, and depression.

</PAST SURGICAL HISTORY/>

Significant for aortobifem bypass. She had an axillary popliteal bypass. She has had a
thrombectomy of the axillary popliteal bypass. She has had prior coronary artery bypass grafting,
hysterectomy, and the above-mentioned right above-knee amputation.

</MEDICATIONS/>
Reviewed per admission database.

</ALLERGIES/>
PENICILLIN and CEPHALOSPORINS.

</SOCIAL HISTORY/>
She had been a smoker in the past. Does not drink or use drugs.

</FAMILY HISTORY/>
Negative for cancer or heart disease.

</REVIEW OF SYSTEMS/>
As mentioned above. Otherwise, she denies any constitutional symptoms. She has mild ______.
She denies any headaches, blurry vision, double vision, sinus congestion. Denies any chest
pain, palpitations, orthopnea, exertional dyspnea. She denies any cough or sputum production.
She denied any gastrointestinal complaint, melena, hematochezia, diarrhea, or constipation.
Denied any dizziness or lightheadedness. She denied any ______ otherwise negative.

</PHYSICAL EXAMINATION/>
VITAL SIGNS: Blood pressure 134/80, pulse is 74, respirations 18, temperature afebrile.
GENERAL: This is a 63-year-old white female, lying supine in bed, in no apparent distress.
HEENT: Normocephalic, atraumatic. Extraocular movements intact. Pupils are round and
reactive to light. Sclerae clear. There is no icterus. Oral mucosa moist. Nares are patent
bilaterally.
NECK: Supple without jugular venous distention or carotid bruits. No lymphadenopathy or
thyromegaly appreciated. Trachea is midline.
HEART: Regular rate and rhythm with S1, S2. No S3 or S4. There are no murmurs.
LUNGS: Clear.
ABDOMEN: Soft, nondistended. Positive bowel sounds x4 quadrants. No hepatosplenomegaly
or masses noted.
EXTREMITIES: Right above-knee amputation. Otherwise, lower extremities are intact. There is
no edema, cyanosis, or clubbing.
NEUROLOGICAL: She is awake, alert, and oriented. Cranial nerves 2 through 12 are grossly
intact. No motor or sensory deficit was found.

</LABORATORY DATA/>
There are no labs available.

</ASSESSMENT/>
1. Above-knee amputation stump infection.
2. Diabetes mellitus, type 2.
3. Hypothyroidism.
4. Peripheral arterial disease.
5. Coronary artery disease.
6. Hypertension.
7. Dyslipidemia.
8. Depression.
9. History of tobacco abuse.

</PLAN/>
Admit to Regency Hospital of Toledo. We are going to continue with her current medication
regimen. Continue with local wound care. I will consult Dr. Borrillo for wound care. We are going
to continue with insulin sliding scale, Levemir, etc. to optimize glycemic control and we will make
further recommendation and plans as appropriate. Database her current progress.