Final answer:
The medical report details the case of a 60-year-old diabetic male, Mark, who developed an infection after sustaining a leg wound while gardening. His symptoms included redness, swelling, and fever, and he was treated with intravenous antibiotics and supportive care.
Step-by-step explanation:
Medical Report
Subject: Mark, a 60-year-old male
Background: Patient has a history of type II diabetes, managed with diet and exercise.
Incident: Patient sustained a minor abrasion on the lower leg while gardening and did not immediately cleanse the wound, instead waiting until evening to apply antibiotic ointment.
Symptoms: Over the following 48 hours, the patient experienced increasing redness, swelling, and warmth in the wound area, alongside deep muscle soreness. After 24 hours, these symptoms were accompanied by fever and leg stiffness.
Diagnosis: Potential bacterial infection likely introduced from the gardening incident and exacerbated by delayed wound care; possibly cellulitis. The patient's diabetic status may complicate the infection and healing process.
Treatment: Upon presentation to the emergency department, the patient was admitted and started on intravenous antibiotic therapy to combat the infection. Limb elevation, cold compresses, and nonsteroidal anti-inflammatory drugs (NSAIDs) were also recommended to manage swelling and discomfort.
Medication: IV antibiotics (specific type to be determined based on culture and sensitivity results), oral NSAIDs for pain and swelling.
Prognosis: Positive, with aggressive treatment and wound care; however, close monitoring is required due to the patient’s diabetes and potential for delayed healing.
The 500 words sample scenario represents an occasion of bacterial infection following a minor injury.