DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: This (XX)-year-old gentleman had had fever, malaise, and elevated white count for about three weeks. He had had a documented urinary tract infection and had been treated with Bactrim according to cultures, ending about 10 days prior to this hospitalization. Unfortunately, he had continuing fevers. He had also received a subsequent course of Levaquin. On the morning of admission, he had malaise. He was seen in an outpatient clinic and had a white count of 26,500. He was sent to the emergency room.
He has an extensive past medical history, including a traumatic cervical tetraplegia about 15 years back. He has had recurrent urinary tract infections, remote ethanolism, COPD, chronic spasm requiring a baclofen pump insertion, suprapubic catheter, Greenfield filter, and acne rosacea. Earlier this year, he had a diverting colostomy. He has had skin wound issues in the past and has been seen in wound clinic for a current wound. He had been a cigarette smoker for many years and was originally ventilator independent after a spinal cord injury. After a couple of years, however, he developed pneumonia and has been on overnight mechanical ventilation since that time. He has had a stage III/IV left ischial decubitus that has been followed by Plastic Surgery.
ALLERGIES: He has no known medication allergies.
SOCIAL HISTORY: The patient lives at home with his family and has nursing assistance for about three hours per day.
PHYSICAL EXAMINATION: VITAL SIGNS: On initial physical examination, his temperature was 97.6 degrees, pulse 102, respirations 22, and blood pressure 114/62. His weight is about 178 pounds, and he is 62 inches. GENERAL: He was well developed and heavy with acne rosacea. HEENT: Head and neck exam was normocephalic with rosacea as noted. Oral and nasal mucosa was moist. The tracheostomy site was clean. NECK: Showed no JVD or bruits. CHEST: Showed good air movement bilaterally with inspiratory and expiratory rhonchi. ABDOMEN: Soft and globular. Bowel sounds were positive. The colostomy site was clean with mucous membrane being pink. EXTREMITIES: Showed trace edema at the feet. There was a grade 4 left ischial decubitus.
INITIAL IMPRESSION:
1. Urinary tract infection.
2. Possible wound infection.
3. Stage IV left ischial decubitus.
4. Chronic respiratory failure.
5. Chronic obstructive pulmonary disease.
6. Tetraplegia.
7. Spasm.
8. Rosacea.
9. Chronic rhinitis.
HOSPITAL COURSE: The patient was given tobramycin and vancomycin in the emergency room and was admitted to the medical floor. He made a recovery, on these antibiotics that was progressive. He was seen by the plastic surgery service. After 48 hours, his white blood cell count was 11,000 with hemoglobin of 11.8. The electrolytes were normal with an albumin of 3.6. Eventually, it was found that his urinary tract infection was gram-negative rods only, and he was limited to tobramycin pending cultures. On MM/DD/YYYY, his random tobramycin level was a bit high, and the dose was reduced. He was seen by Plastic Surgery, and arrangement was made for him to get into the operating room for debridement on MM/DD/YYYY. There was a strong suspicion, after the procedure, of osteomyelitis. The left ischial bone eventually grew Streptococcus faecalis, Klebsiella pneumoniae, and additionally a Bacteroides species. He had an intermittent issue of worsening of his respiratory status and required prednisone administration with resolution eventually. His blood sugars were also problematic, and they had been modestly so in the past, and he was started on insulin coverage and eventually Glucophage. He required PICC line insertion for intravenous antibiotics that were to be continued for four weeks. He is on a tapering course of prednisone, and at the time of discharge, was down to about 5 mg and again required Glucophage. He was seen by Dr. John Doe from the infectious disease service and again Dr. Jane Doe from the plastic surgery service. His last laboratory tests showed a normal white count, chemistries, and a modest anemia with hemoglobin in the 11 range. The sensitivities on the bacteria in the bone allowed for treatment with amoxicillin by mouth and meropenem intravenously. Vitals signs on the last hospital day were a pulse of 80, respirations 18, and blood pressure 132/82. Accu-Cheks ranged from 115-218.
DISCHARGE MEDICATIONS: Colace 100 mg three times a day; baclofen 20 mg t.i.d., 30 mg at bedtime; Valium 2 mg t.i.d., 10 mg at bedtime; Zanaflex 4 mg twice a day and 10 mg at bedtime; Senokot 2 daily; Pepcid 20 mg at bedtime; Enemeez suppository in the evening; Detrol 2 mg twice a day; vitamin C 500 mg twice a day; Theo-Dur 200 mg twice a day; Celexa 20 mg once a day; Advair inhaler 250/50 mcg one dose a.m. and p.m.; multivitamin once a day; acidophilus 2 tabs 4 times a day for 5 weeks; Sudafed 120 mg twice daily as needed; Flonase 2 puffs each nostril once to twice a day; steroid cream to the face twice a day as needed; Ambien 10 mg at bedtime as needed for sleep; Enulose 15 mL as needed for constipation; prednisone 5 mg once daily for 3 days; Glucophage 500 mg a.c. breakfast and dinner; Tylenol No. 3 every 4 hours 1-2 as needed for pain; dressing changes twice a day requiring moist packing into the wound covered by dry sterile dressing; the ventilator set at volume of 950 with a rate of 10 and 3 mL in the tracheostomy tube. He will use cuff inflator as needed and is expected to be off the ventilator with a cap to trach during the day. The patient also has inhaled medication for rescue as needed.
DISCHARGE DIAGNOSES:
1. Urinary tract infection.
2. Osteomyelitis.
3. Chronic respiratory failure.
4. Chronic obstructive pulmonary disease.
5. Spasm.
6. Acne rosacea.
7. Bowel and bladder incontinence.
DISCHARGE DISPOSITION: The patient will be discharged to home with home care as noted.
FOLLOWUP: Office followup with Plastic Surgery and our office and physiatry has been arranged.
