-
HISTORY
1. Chief Complaint
- Pt's perception of problem
- His goals
-
HISTORY
2. Present Illness
- Onset; date, speed; rash, trauma, callus
- Past & present Tx and cleaning method, response
- Sx associated with Ulcer
- Pain; Location, Quality, Severity, Timing, Modifying factors
-
3. HISTORY
Past Medical
- Circulation; PAD, PVD & risk factors. VI & DVT
- hematologic, microthrombotic disorders, Vasospastic
- Liver disease/ hep C
- Inflammatory; Autoimmune (RA, Scleroderma, SLE) inflammatory bowel disease
- Metabolic; DM, renal failure/insuff. (nutritional, calciphlaxis)
- Infection hepatitis, TB, HIV
- Neuro neuropathy, paralysis, paresis
- Musculoskeletal
- Surgeries
reconstructive, revascularization (stents, bypass, angioplasty) vein stripping, amputation - accidents lower extremities; gait, CVI, hardware
-
HISTORY
4. Current Health
- Meds; steriods, chemo
- Allergies
- Habits; smoking, alcohol, illecit drugs
- Diet; appetite, intake, special needs
-
HISTORY
5. Family History
- genetic related diseases
- DM, HD, HTN, CVA, TB, Ca, arthritis, kidney disease, lower extremity wounds
-
HISTORY
6. Social history
- living arrangement; able to help with wound care
- Leisure activities enjoyed and how wound affects this
-
|
|
