CHIEF COMPLAINT: Serosanguineous discharge.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with multiple medical problems including pyogenic granuloma of the right knee, hypertension, morbid obesity, depression, chronic right leg DVT, and hypothyroidism. The patient is status post right knee total replacement and developed a chronic pyogenic granuloma in that knee that has recently, before admission, started draining serosanguineous discharge. The patient presented to the clinic with this discharge and was admitted for wound debridement.
PAST MEDICAL HISTORY: The patient has a history of hypertension, morbid obesity, depression, chronic right leg DVT, hypothyroidism, and pyogenic granuloma of right knee status post replacement.
PAST SURGICAL HISTORY: The patient has a past surgical history of right total hip replacement, total knee replacement, and Greenfield filter placement.
ALLERGIES: No known drug allergies.
MEDICATIONS: Lopressor 100 mg twice a day, Synthroid 0.125 mg once a day, Cozaar 100 mg once a day, Cardura 16 mg before bedtime, Duragesic patch 50 mcg every 72 hours, Dilaudid 4 mg every morning and 2 mg every evening, Lasix, K-Dur, Citrucel, and lactulose.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with his wife and is on disability. The patient denies smoking and alcohol use.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature is 98.8 degrees, pulse 60 beats per minute, respirations 16 breaths per minute, and blood pressure 132/82 mmHg. GENERAL: The patient is in no respiratory distress, wheelchair bound. HEENT: The patient’s head is normocephalic and atraumatic. Pupils are equal and reactive to light and accommodation. Extraocular movements are intact. There is no conjunctival pallor or scleral icterus. There is no lymphadenopathy. HEART: Regular in rate and rhythm with no murmurs, rubs, or gallops. LUNGS: Clear to auscultation bilaterally with good air entry. There are no wheezes, rhonchi, or crackles. ABDOMEN: Soft, nontender, and obese with bowel sounds in all four quadrants. There is a ventral hernia in the midline. No apparent organomegaly. EXTREMITIES: The patient’s right knee has a wound that is draining serosanguineous discharge. There is pedal edema bilaterally. NEUROLOGIC: The patient is alert, awake, and oriented x3. There are no focal neurologic deficits. The patient is slightly hard of hearing.
LABORATORY DATA: The patient was found to have a low white blood cell count of 3.3 upon admission. The patient was also found to be anemic with hemoglobin of 10 upon admission. The patient’s sed rate was 48. The patient’s PT was 28.2 with an INR of 2.8 upon admission. Culture of the discharge from the knee revealed methicillin-resistant Staphylococcus aureus or MRSA and Staphylococcus epidermidis or Staph epi.
IMAGING STUDIES: The patient had a chest x-ray upon admission, which showed vascular congestion and crowding with no infiltrate. The study was limited by suboptimal inspiration. The patient had a CT of the right knee on admission. It was a limited study due to metallic artifact. The patient had a white blood cell scan with bone marrow correlation. It was found to have a focus of active infection along the anterolateral aspect of the distal right thigh.
HOSPITAL COURSE: The patient was admitted for surgical debridement of pyogenic granuloma of his right knee. On a preoperative nuclear stress test, the patient was found to have some mild ST changes. After clearance by Cardiology, the patient had debridement of his pyogenic granuloma. The patient had a PICC line placed. Postoperatively, a VAC dressing was used for healing, and the patient was started on long-term IV antibiotics. The antibiotics used were vancomycin and Cubicin. During the postoperative period, the patient became anemic and required transfusion of 2 units of packed red blood cells. The patient was also started on Lovenox and Coumadin, and while on Lovenox, developed a hematoma at the site of Lovenox injection. This complication resolved shortly thereafter. The patient was discharged to an outpatient rehabilitation facility for long-term antibiotic use through the PICC line and wound care.
