88, F, PMH of lymphedema, vascular disease, Hx of PE, Chronic embolism and thrombosis of other veins, long term Xarelto use, Lipoid dermato-arthritis, Hyperlipidemia, HTN, osteoarthritis. Patient has bilateral lower extremity ulcers and petechial rash (wondering if wound and rash are related). Arterial Duplex and wound biopsy were un remarkable. The larger wound is on left lower extremity & has been present since August, 2021. The smaller wound on the R lower extremity has been present for about a month (progressed very quickly). I took a PCR swab of the wound and treated her orally with Levaquin as the wounds were rapidly increasing in size, they had excessive drainage, and a foul odor. She is being treated topically with metrogel. The patient has previously tried dressing changes by home care nurse including use of mupirocin ointment, calcium alginate, Santyl, iodosorb, hydrofera blue ready, and foam dressings. Patient complains of bilateral lower extremity pain that is worse at night and relieved by walking (questioning if arterial doppler was incorrect). I plan to repeat arterial doppler and ABI. Patient doesn't tolerate wound cleanser or acetic acid as almost everything that touches her wounds causes extreme burning pain. She allowed me to complete debridement on the left leg ulcer, but it was extremely painful even with topical and injectable lidocaine. She will allow her wounds to be cleaned only with poured normal (she says the normal saline spray is painful). I have been treating her with ultramist 2x weekly for 3 weeks without improvement.

Medications: olmesartan-hydrochlorothiazide, ropinirole, Xarelto, allopurinol, clopidogrel, cholecalciferol (vitamin D3)
Her only new medications are Levaquin and metrogel. The rash was present prior to starting Levaquin and metrogel.