DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, DPM
REASON FOR CONSULTATION: Evaluation and management of left hallux cellulitis.
Thank you for this infectious disease consultation.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with long-standing diabetes mellitus, who recently was treated with antibiotics for cellulitis involving the right foot as a result of a thermal burn, as she walked on hot pavement. This was treated with linezolid; however, the patient returned to the hospital because of increasing swelling and redness of the left big toe. The patient stated that the ulcer of the left toe started several weeks ago, but the redness and the cellulitis just started up about three to four days prior to admission. The patient has been admitted since the last five days and has been treated with Zosyn monotherapy with really minimal results. As a result, infectious disease consultation was requested. An MRI of the foot, on the left, was ordered to evaluate for the presence of osteomyelitis. The patient is otherwise feeling well. She does not have any other major complaints.
PAST MEDICAL HISTORY: Hypertension, insulin-dependent diabetes, coronary artery disease, hypercholesterolemia, COPD, anxiety, history of CDT positivity, ovarian cyst, diabetic neuropathy, panic attack, and peptic ulcer disease.
PAST SURGICAL HISTORY: Quadruple bypass surgery.
MEDICATION: List has been reviewed.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient lives with her family members, including her husband and daughter. She does not use tobacco, alcohol or drugs. She is disabled.
FAMILY HISTORY: Positive for myocardial infarction, diabetes, and coronary artery disease. No immune dysfunction.
REVIEW OF SYSTEMS: No shortness of breath, chest pain or other cardiorespiratory complaints. No gastrointestinal symptoms such as nausea, vomiting or diarrhea. She does not have any other musculoskeletal complaints. She does have chronic peripheral neuropathy. No other focal neurologic complaints. The full 14 points were reviewed with the patient and are negative other than mentioned above.
PHYSICAL EXAMINATION: The patient is alert, oriented, and in no acute distress. She is currently afebrile with a temperature of 98.8, pulse 100, respirations 18, and blood pressure 144/77. Head is normocephalic and atraumatic. Pupils are equal and reactive to light. Nares are patent. Sinuses are nontender. Oropharynx is clear without lesions. Neck is supple without lymphadenopathy. Heart has regular rate and rhythm. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender, obese, and nondistended. An insulin pump was in place, and the area where the insulin tube was inserted appears to be in good position without surrounding cellulitis. The inguinal area appears normal. The right foot appears unremarkable. She does have an area of a skin graft scar over the right calf where she underwent previous surgery. The right toes are hyperkeratotic, but otherwise unremarkable. Over the left major toe is an area of increasing erythema. There is also an ulcer that is on the lateral aspect of the great toe. There is cellulitis and tenderness over the entire toe and extends throughout the perimeter of the great toe.
LABORATORY DATA: Laboratory data has been reviewed in this patient. The white count was 7.8 yesterday. The wound drainage of the left toe has been received and is currently pending. Urine culture has not grown any organisms.
IMPRESSION:
1. Cellulitis of the left great hallux with minimal improvement, if any, on Zosyn monotherapy.
2. Diabetes mellitus, insulin dependent.
MEDICAL DECISION MAKING: A couple of reasons why the patient may have failed therapy are:
1. It is possible the patient could have osteomyelitis.
2. The patient may not have been treated for possible MRSA.
RECOMMENDATIONS:
1. Add daptomycin for possible MRSA coverage. She did well last time on linezolid for her cellulitis.
2. Would be more aggressive with left leg elevation.
3. Will check a urine assay to rule out gouty arthritis; although, this is most likely cellulitis.
4. Agree with MRI to rule out osteomyelitis in this patient.
Thanks for allowing us to participate in this patient’s care. We will continue to follow with you.
