ALBANY STATE UNIVERSITY

COLLEGE OF SCIENCE AND HEALTH PROFESSIONS

FAMILY NURSE PRACTITIONER PROGRAM
Episodic Care Information Sheet
STUDENT NAME: Alexander Warren
PT. S.M.

RRACE: White A AGE: 68

DATE: 2/14/2015
SEX: Female ENCOUNTER DATE: 2/10/2015

SUBJECTIVE
Chief complaint/concern: There is was a bloody patch on my sheets this morning when I woke
up and my right buttocks hurts. I think I have a wound
HPI: 68 year old Caucasian widowed female presents today for an evaluation of pain in her right
buttocks. She states that it has been painful for 2-3 days but when she woke up this morning
there was blood on her sheets. She says she thinks there is a wound on her right buttock but
cannot see it in the mirror. She took OTC Tylenol for the pain. She states that she took 3 tabs of
Tylenol this morning but does not know the mg of the tabs.
Past Medical History:
HTN.
DM type II.
CVA in 2009
Hyperlipidemia.
Hypothyroidism
Atrial Fibrillation
Allergies: Demerol
Current Medications: Lisinopril 10 mg daily, Metformin 500 mg twice a day, Actos 30mg
daily, Simvastatin 20 mg daily, Coumadin 2 mg Mon, Wed, Fri, Coumadin 3 mg Tues, Thurs,
Sat, Sun
Immunizations: Up to date.
Family Health Hx: Mother and father deceased both with diabetes and heart disease.
Grandmother had cervical CA.
Social History: Widower since husband passed away 7 years ago. Lives alone in a house. Has
three living sons, all of which live near her in Valdosta. She states they help her when she needs
it. Denies any alcohol, tobacco, or drugs.
Review of Systems:

General: Denies fever, chills, difficulty sleeping, unintentional weight loss/gain, or fatigue.
EENT: Denies any visual disturbances, headaches, dizziness, ear pain/drainage. Denies any
nose bleeds or other nasal discharge. Denies sore throat, swelling/pain of the tongue, or bleeding
of the gums.
Respiratory System: Denies any wheezing, shortness of breath, cough, or mucous production.
Cardiovascular: Denies any palpitations, chest pain, swelling of extremities, coldness in
extremities, or exertional dyspnea.
Gastrointestinal system: Denies any pain of the abdomen, nausea, vomiting, change in appetite,
indigestions, constipation, or diarrhea. Denies any blood in his stools.
Genitourinary system: Denies nocturia, urinary frequency/urgency, incontinence, or urinary
retention.
Skin: Complains of bleeding from her right buttocks. She is unsure of what it is but is pretty
sure there is a wound there. She states the pain began 2-3 days ago but did not think much of it
until she saw the blood this morning. She denies any other skin problems. No rashes, changes in
moles, peeling, or cracking.
Endocrine: Denies any heat or cold intolerance. Denies any hair changes. Denies any dry skin
or excessive thirst.
Musculoskeletal System: Denies any joint pain, swelling, or stiffness. Denies any difficulty
walking, muscle pain, or cramps.
Neurologic System: Denies any change in mental status, increase forgetfulness, or nervousness.
Pscyh: Denies insomnia, anxiety, or depression.
Objective
BP: 136/88 O2 sat: 97% P: 74
Random Blood Sugar: 143

R: 18 Temp: 99.2

HT: 61 inches Wt: 172 pounds

Physical Examination.
A. General: Healthy appearing 68 year old Caucasian female who is well developed and
well nourished in appearance. No distress or anxiety noted.
B. Head: Normocephalic. Normal hair distribution. Negative TMJ. No lymphadenopathy
or sinus tenderness noted.
C. Eyes: PERRLA.
D. Ears: Tympanic membranes intact and pearly gray in color. No fluid or irritation noted.
No masses or lesions.

E. Nose: Septum midline. Nasal turbinates not swollen and nasal passages are clear.
Mucosa pink and moist. No polyps noted.
F. Mouth: Dentition in good repair. Mucosa pink and moist. Tongue midlines with no
lesions or swelling noted. Gums pink with no disease or bleeding noted.
G. Neck: No lymphadenopathy noted. Thyroid reveals no enlargement or masses. Trachea
midline. Symmetrical and supple.
H. Skin: There is a wound on the patients right buttock that is 2 cm X 3.5 cm in size.
There is a mild amount of bloody drainage. The area of redness extends all around the
wound by 2 cm. Induration noted. The wound is painful to touch. No foul smell. No
depth to wound, it involves epidermis and dermis only. No necrosis noted.
I. Respiratory: Chest rise and fall is symmetrical. Respirations are unlabored. Breath
sounds are clear.
J. Cardiovascular: S1 and S2 heard. No murmurs, rubs, or gallops noted. Rhythm regular.
K. GI: Abdomen reveals no distention. No pulsations noted. Bowel sounds noted in all 4
quadrants. No tenderness to palpation.
L. Gu: Deferred.
M. Lymphatic: No lymphadenopathy or tenderness noted.
N. Musculoskeletal: Normal gait. Full range of motion and denies pain with movement. No
crepitus noted.
O. Neuro: Cranial nerves II-XII intact. Patient alert and oriented. Full strength noted in
upper and lower body.
Lab Findings/Diagnostics: Wound culture positive for MRSA.
DIFFERENTIAL DIAGNOSIS;
1.
2.
3.
4.

MRSA infection with resulting wound.

Pressure ulcer.
Spider/insect bite.
Cellulitis.

Assessment/Final Diagnosis:
1. MRSA infection of right buttock. 041.12
2. Open wound. 877.1
3. HTN. 401.9
4. Diabetes type II. 250.00
5. Atrial Fibrillation. 427.31
6. Hyperlipidemia. 272.4
Plan:
1. Bactrim DS 160/800 2 tabs twice a day for 14 days.
2. Bactroban ointment. Apply to wound twice a day with dressing changes.
3. Cleanse wound with wound cleanser, cover with TELFA pad, and dry dressing twice a
day.

4. Wash body with Hebiclens nightly.

5. Home Health to see patient daily to change dressing with patients son is at work and to
monitor wound.
6. Culture wound.
7. Follow up in one week to reassess wound and for results of wound culture.
Health Promotion Issues and Education
Wash hands thoroughly and frequently to prevent spread of MRSA. Whenever you are in
contact with the wound always wash your hands. Do not scratch lesions as this can cause
secondary infections which could lead to serious problems. Keep the wound covered to prevent
drainage from contaminating other areas of your body. If any drainage gets on bed sheets, wash
them prior to further use. Use sunscreen when working outside to reduce the risk of skin cancer.
If you notice any side effects from new medications call the office or come in immediately.
Keep current infected area clean and dry. Avoid abrasive chemicals that could irritate the skin,
use detergents that are free from colors and scents. Discussed ADA diet and handouts were
given. Encouraged to keep a food diary and a blood sugar log. Low fat/no added salt diet
recommended due to HTN/hyperlipidemia. Ensure continued yearly flu shots and recommended
a pneumonia/shingles vaccination. Patient refused. Continue annual visits with GYN and keep
colonoscopies up to date.
Discussion: My preceptor and I were very concerned upon seeing the wound as MRSA
infections can quickly become severe. The large area of induration was the determining factor in
the primary diagnosis of MRSA as these types of infections usually go deep. We were very
surprised that the patient did not complain of severe pain with the wound as it was warm to touch
and had a large area of erythema around the wound. This was possibly due to the patients 40
year fight with diabetes and the resulting loss of sensation but that cannot be confirmed. The

patient was prescribed a double dose of Bactrim DS by Bill and this was new to me as my
previous physicians did not do that. When asked why, she stated that she has seen better results
using that dosage. I did some research on dosing Bactrim DS for MRSA and found several
articles relating to which dose was better; the single or the double. All seemed to return the same
results; MRSA SSTIs treated with two different doses of TMP/SMX (160/800 mg twice daily
versus 320/1,600 mg twice daily for 7 to 15 days) had similar clinical resolutions. A higher dose
of TMP/SMX may not be necessary to treat patients with skin and soft tissue infections caused
by methicillin-resistant Staphylococcus aureus. (Cadena, 2011) It seems that the double dosage
is not necessary but I could not find where it was detrimental either. I guess it is physician
choice and the results are probably anecdotal. The patient was also given Bactroban and orders
to change the dressing twice a day. Due to where the wound is located the patient obviously
cannot change the dressing herself so Home Health was ordered for treatment and wound
monitoring. I am a huge advocate for Home Health and the necessity of it in this particular case
was glaring. Bill stressed to the patient the need to wash her hands frequently to prevent
further contamination. Also, she stressed the need to wash bed linens and anything else that was
potentially exposed to the drainage. It is found that, To help minimize the spread of MRSA,
hand hygiene must be coupled with effective routine environmental cleaning (Moore, 2011)
Overall I agree with Bills treatment of the patient. Whether or not doubling the dose of the
Bactrim DS is more effective than the single dosage, the end result is the same.

Cadena, J., Nair, S., Henao-Martinez, A. F., Jorgensen, J. H., Patterson, J. E., & Sreeramoju, P. V.
(2011). Dose of Trimethoprim-Sulfamethoxazole To Treat Skin and Skin Structure

Infections Caused by Methicillin-Resistant Staphylococcus aureus. Antimicrobial Agents

and Chemotherapy,55(12), 5430-5432. doi: 10.1128/AAC.00706-11

Moore, G., Cookson, B., Jackson, R., Kearns, A., Singleton, J., Smyth, D., & Wilson, A. (2011).
MRSA: The transmission paradigm investigated. BMC Proceedings, 5(Suppl 6), O86. doi:
10.1186/1753-6561-5-S6-O86

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