Complete Shadow Health Infection Assessment for Patricia Young. Right lower leg cellulitis with spreading erythema, wound assessment (5cm × 3cm with purulent drainage), fever 38.6°C, WBC 14.2, blood cultures, culture and sensitivity ordered. Poorly controlled T2DM (HbA1c 9.2%). Diagnosis: Cellulitis — local skin and soft tissue infection.
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Patricia Young presents with a wound on her right lower leg that has become increasingly red, warm, swollen and painful over 3 days. She reports fever, chills and fatigue. She has a history of Type 2 Diabetes (HbA1c 9.2%) which significantly increases her infection risk and impairs wound healing.
The Infection Assessment covers a complete wound assessment (size, depth, drainage, streaking), vital signs including fever documentation, laboratory results (CBC showing WBC 14.2), blood cultures, wound swab for culture and sensitivity, and diabetic foot care education.
Wound: 5cm × 3cm erythema with proximal streaking. Temp 38.6°C. WBC 14.2. Diagnosis: Cellulitis with local soft tissue infection. Antibiotic plan, wound care and admit vs. outpatient decision documented.