Subjective: Nausea, diarrhea, low grade fever 99.7, syncope, low back pain and generalized malaise.
HPI: This is a 78 year old Caucasian female being admitted to James Squares Health and Rehabilitation today for extensive deconditioning. Patient was admitted into the hospital on 3/4/2014 with hypotension, leukocytosis and lactic acidosis. Patient during transport to the emergency room via ambulance and was noted to become hypotensive with SBP pressures in the 100’s. On arrival the patient underwent diagnostic testing that revealed elevated WBC’s of 29,000 with a left shift and lactic acid of 3.8. Patient’s troponin was elevated at 0.79 and K+ 2.8. Patient underwent a CAT scan which showed thickening of the transverse Colon.
PMH: Vertigo, Arthritis, Diverticulitis, Anxiety Past Surgical History: Hysterectomy 2007, Cholecystectomy, Diverticulitis resulting with a splenectomy and colostomy with a reversal in 1998, Bladder and Pelvic floor surgery Family History: Mother died age 84 from a CVA and had a history of leukemia, Father died age unknown with a history of alcohol abuse Allergies: Medication allergy to PCN and Z-pack, No environmental, latex or food allergies Accidents/Injuries: None Social History: Smoked 50 years ago, denies alcohol or drug use
Medication List: New medications Amlodipine Besylate 10 mg po q day hypertension Aspirin 81 mg po q day anticoagulant Enoxaparin sodium 40mg po q day DVT prophylaxis Lidocaine patch 5% one patch topically q 24 hours Pain Meclizine HCL 12.5 mg po qid prn vertigo Oxycodone HCL/Acetaminophen 5-325 mg po q 8 hours and q 6 hours prn pain Pantoprazole sodium 40 mg po q day GERD Polyethylene Glycol 3350 17 gm po q day prn constipation Probiotic one tab po bid antibiotic diarrhea prophylaxis Tramadol-acetaminophen 37.5-325mg one tab po q 8 hours prn pain Immunizations: Up to date per CDC guidelines
General: Denies fever, chills and generalized malaise or excessive sweating. Patient states 20 lb. weight loss after the death of her spouse and has been slowly gaining weight back. Denies intolerance to heat or cold Skin: Denies rashes, itching, dryness, and lumps, changes in texture or pigmentation, Denies history of eczema or other skin disorders. Head: Denies headaches or head injuries. Pt states history of vertigo Neck: Denies lumps, difficulty swallowing pain or stiffness Ears: Denies pain, discharge, or chronic infections. Patient with use of hearing aids bilateral ears.
Eyes: Denies visual changes, excessive tearing, and history of glaucoma, cataracts, redness, or pain. Patient states she wears glasses for reading and distance vision Nose and Sinuses: Denies nasal drainage, itching, sinus pain or previous infections. Mouth and Throat: Denies sore throat, tooth pain or infections, difficulty swallowing or hoarseness of voice. Patient states last bout of strep throat was three years ago. Respiratory: Denies SOB, difficulty breathing or wheezing. Denies history of asthma Cardiac: Denies history of heart disease, chest pain, chest pressure or heaviness, denies history of MI, heart palpitations, or heart murmur. Last EKG performed during recent hospitalization
Peripheral Vascular: Denies leg cramps, claudication, varicose veins, or history of clots in legs. Gastro-Intestinal: Denies change in appetite, nausea, vomiting, diarrhea, or constipation at this time. Urinary: denies polyuria, nocturia, dysuria, urgency, or incontinence. Denies history of urinary tract infections Musculoskeletal: Complaint of generalized weakness, history of arthritis, with muscle stiffness, and joint pain primarily in the right shoulder, Complaint of lower back pain, Denies history of fractures. Hematological: Denies easy bruising or abnormal bleeding. Recent hospitalization with blood transfusion, denies a history of anemia
Endocrine: denies intolerance to heat or cold, excessive sweating, polyphagia, polydipsia or polyuria. Psychiatric: Patient with history of anxiety Neurological: History of vertigo with recent episode of unconsciousness prior to hospitalization, denies history of dizziness, weakness, paresthesia, seizures, tremors, loss of memory, or unsteadiness of gait.
General: Alert and oriented elderly female who appears well nourished and well groomed. Patient is lying in bed at a 75 degree angle in no acute distress. Skin: Pale pink, warm and dry. Hair is thick, white and distributed evenly over scalp. Skin turgor without tenting, No dryness, scaling or rashes or pigmentation changes noted. Nail beds pink and capillary refill is brisk. Dry crusty scabs noted on left buttock and left lower back. Lidocaine patch to lower back, large abdominal scar noted from sternum to pubic bone, 5 cm scar noted on left abdomen. Right upper arm with a 5 French dual lumen catheter Picc in place with dressing intact
Head and Neck: ROM within normal limits. Head normocephalic and atraumatic, Neck is supple with no masses or bruits. No cervical lymph adenopathy noted. Thyroid is not enlarged or tender on palpation, thyroid nodule noted on CT of the spine measuring 1.6 cm, No JVD noted. Ears: No tenderness is palpated over mastoid process. External ears with no swelling or drainage, Tympanic membranes intact and pearly gray in color bilaterally. No pain or discharge noted, Cones of light seen bilaterally, ears free of cerumen impaction Eyes: PERRLA. Eyes are without redness, drainage and swelling, Sclera white, conjunctiva pink bilaterally. Extraocular movements are present
Nose and Sinuses: Nose midline. Nasal passages patent. No frontal or maxillary tenderness. Mucosa is clear of redness or swelling. Mouth and Throat: Lips are pink, intact without ulceration. Oral mucosa is pink, smooth, without masses or ulcers. Tongue is midline, native dentition in good repair, all teeth present, palate pink, and no ulcers present. Trachea is midline. Tonsils: present without exudate. No pain on swallowing. Uvula midline Respiratory: Respirations are easy and unlabored upon exam without the use of accessory muscles. Lung sounds noted with rales in the left lower lobe, no wheezing or rhonchi noted,
Cardiac: Rate 84, regular rhythm, S1S2, No chest pain, chest pressure or palpitations at time of exam, No edema. Last EKG sinus rhythm with rate of 89 and some non-specific ST and T- wave changes, History of hypertension Peripheral Vascular: Peripheral pulses +3, equal bilaterally. No leg cramps, varicose veins, or past clots in legs. Homan’s sign negative. Gastro-Intestinal: Abdomen soft, non-tender and non- distended, umbilicus in midline. Bowel sounds present in all 4 quadrants, frequency: 15/ minute, medium pitch. No bruits. No referred pain, rebound tenderness, guarding or wincing on palpation. No hepatomegaly, hernias, or masses. Urinary: No pain in flank, groin, suprapubic region or lower back, no CVA tenderness
Musculoskeletal: Upper extremities: Arms symmetrical in length and muscle mass, joints equal in size and shape bilaterally. Joints with weakness noted in right arm with decreased ROM and muscle strength of 3/5 bilaterally. Lower extremities: Legs symmetrical in length and muscle mass, joints equal in size and shape bilaterally, no obvious deformity or swelling. No varicosities, no edema. Joints with equal ROM and muscle strength of 5/5 bilaterally Neurological: Cranial nerves I to XII intact
Discitis, sometimes spelled diskitis, affects the discs between individual bones of the spine (vertebrae). Swelling in the small spaces between these bones (the intervertebral disc spaces) puts pressure on the discs and causes pain. This condition often goes together with another called osteomyelitis, which involves infection of bone or bone marrow. Discitis is one of several kinds of spinal infection and inflammation. The spine’s surrounding tissue, joints, and vertebrae can also become irritated and inflamed. (Stoltzfus, S & Leonard, M.,2012)
Infection is caused by biofilm bacteria, which protects bacteria from antimicrobial agents and host immune responses. Acute: suppurative infections of the bone with edema and vascular compromise leading to sequestra. Chronic: Presence of necrotic bone or sequestra or reoccurrence of previous infection. (5-minute Clinical Consult, 2014)
Hematogenous osteomyelitis may vary from a mild skin infection to bacterial endocarditis; it is also a complication among intravenous drug users Osteomyelitis secondary to a contiguous focus of infection may be caused by the direct inoculation of bacteria through trauma, from spread of adjacent soft tissue infection, or introduction of infection during preoperative or intraoperative procedures: examples are surgical reduction and internal fixation of fractures, prosthetic devices, open fractures, and chronic soft tissue infections Osteomyelitis secondary to vascular insufficiency is often associated with diabetes mellitus. Infection often results from minor trauma to the feet, such as infected nail beds or skin ulceration. Inadequate tissue perfusion limits local tissue response to injury Multiple organisms are responsible for osteomyelitis in different populations. (Clinical Key, 2012)
PopulationCausative Organism Patients of all ages Neonates Infants and children Intravenous drug users Patients with sickle cell disease HIV-infected Patients Patients with nosocomial infections S. aureus Enterobacteriaceae, group B streptococci Haemophilus influenzae type B S. aureus, Pseudomonas aeruginosa, Candida species Streptococcus pneumoniae, Salmonella species Bartonella henselae S. aureus, Enterobacteriaceae, Candida species, Aspergillus (in immunocompromised patients) (Clinical Key, 2012)
Population Causative Organism Adults (most commonly) Patients with urinary tract infections Intravenous drug users Patients undergoing spinal surgery Patients with infections of intravascular devices Patients living in endemic regions S. aureus Aerobic gram-negative bacilli, Enterococcus species S. aureus, P. aeruginosa Coagulase-negative staphylococci, S. aureus, aerobic gram-negative bacilli Candida species, staphylococci M. tuberculosis, Brucella species, regional fungi, histoplasmosis ), (Clinical Key, 2012)
PopulationCausative Organism Patients exposed to contaminated soil Patients with orthopedic devices Patients with decubitus ulcers Patients with a history of cat bites Patients with a history of human bites (including clenched-fist injury) Patients with puncture injuries on the foot Patients with periodontal infection Clostridium species, Bacillus species, Stenotrophomonas maltophilia, Nocardia species, atypical mycobacteria, Aspergillus species, Rhizopus species, Mucor species S. aureus, coagulase-negative staphylococci, Propionibacterium species Enterobacteriaceae, P. aeruginosa, enterococci, anaerobes, Candida Pasteurella multocida Eikenella corrodens, Moraxella species P. aeruginosa Actinomyces species (Clinical Key, 2012)
All post splenectomy patients have an increased risk of overwhelming bacterial infection. Certain factors however do influence the degree of risk: Age: Younger patients have greater risk Underlying disease: Risk with underlying immunodeficiency > thalassemia > sickle cell anemia > traumatic splenectomy Time since splenectomy: Recent splenectomy has greater risk than many years post-operatively (Clinical Pharmacy, 2014)
The most common cause of overwhelming post- splenectomy sepsis is Streptococcus pneumoniae Pathogens listed below can be a source of serious infection in patients with splenectomies: ◦ Encapsulated bacteria: S. pneumoniae, H. influenza, N. meningitidis ◦ S. aureus ◦ Numerous gram negatives including E. coli, K. pneumoniae, Salmonella sp. and Capnotcytophagia sp. (the latter usually acquired from a dog bite) ◦ Malaria ◦ Babesia (acquired from ticks in the Eastern seaboard particularly Cape Cod, Martha’s Vineyard, Nantucket, Block Island) (Wood, 2014)
Incidence is low due to high resistance of normal bone to infection, occurs in patients with risk factors 25% lifetime risk of diabetics of developing foot complication Up to 66% of diabetics with foot ulcers 1 case per 5,000 children Neonatal prevalence is approximately 1 case per 1,000 The annual incidence in patients with Sickle cell anemia's is approximately 0.36% The prevalence of osteomyelitis after foot puncture may be as high as 16% (30-40% in patients with diabetes) The incidence of vertebral osteomyelitis is approximately 2.4 cases per 100,000 population (5-Minute Clinical Consult, 2014 & King R.W., 2014)
Fever or chills Irritability or lethargy in young children Pain in the area of the infection Swelling, warmth and redness over the area of the infection Sometimes osteomyelitis causes no signs and symptoms or has signs and symptoms that are difficult to distinguish from other problems. (Mayo clinic, 2014)
Restricted movement of the infected extremity or inability to bear weight Pain or tenderness in the infected area Signs of localized inflammation Fever or chills Motor and sensory deficits (vertebral infection) Visible ulcer Diabetics may mask infection and not display clinical signs and symptoms related to vascular disease and neuropathy Diabetics may unexplained fluctuations in glycemic control such as hyperglycemia (5-Minute Clinical Consult, 2014)
WBC is not a reliable indicator and can be normal even when an infection is present CRP is usual elevated but not specific ESR is elevated in most cases Routine radiography is first-line imaging: bone destruction is not apparent until 10-21 days of infection and must undergo 30-50% damage until visible MRI for visualization of septic arthritis, spinal infections and diabetic ulcers CT is better than radiography in fragments and sequestration but is inferior to MRI for soft tissue and bone marrow evaluation (5-Minute clinical Consult, 2014)
Empiric treatment is based on causative organism Duration of antibiotic therapy 4-6 weeks for acute osteomyelitis and > 8 weeks for chronic osteomyelitis or MRSA Surgery Nutrition Smoking-Cessation therapy Control Diabetes Hyperbaric oxygen therapy Negative pressure wound therapy (5-Minute Clinical Consult, 2014)
23-valent Pnemococcal Polysaccharide Vaccine, PPV-23 (Pneumovax®). This vaccine only produces an immune response in individuals > 2 years of age 7-valent Protein-Conjugated Vaccine, PCV- 7 (Prevnar®), which produces an immune response and is safe beginning at 6 weeks of age. It has not been well studied in older patients. (Clinical Pharmacy, 2014)
Children less than 2 years of age should receive PCV-7 at the usual ages recommended for children their age: 2, 4, 6 and 12-15 months of age. These children should be given PPV-23 at 2 years of age. Children 2 to 5 years of age should receive two doses of PCV-7 given 2 months apart, followed > 2 months later by a dose of PPV- 23. Older children and adults should receive the PPV23. A booster PPV23 should be given approximately 5 years after the initial vaccine/series for patients with asplenia. Quadrivalent conjugated meningococcal vaccine should be given to all asplenic individuals > 2 years of age Hemophilus influenza vaccine should be given once to all individuals > 2 years of age and at the time of routine vaccination for younger children. (Clinical Pharmacy, 2014)
The issue of antibiotic prophylaxis in these patients is controversial. The only regimen which has been studied is penicillin prophylaxis for patients with functional asplenia from sickle cell anemia. Resistance to penicillin and other antibiotics is a growing concern. Compliance with an indefinite daily regimen is extremely difficult. (Clinical Pharmacy, 2014)
The patients who are most likely to benefit from prophylaxis are: Children < 5 years of age Individuals who have had splenectomy within the past year Those with an underlying immunodeficiency in addition to splenectomy (Clinical Pharmacy, 2014)
CBC q Thursday while on Lovenox to monitor for heparin induced-thrombocytopenia CRP, CBC and BMP q week: please fax copy to Dr. Gehman infectious disease Pneumovax 23 0.5ml IM x one CT of abdomen and pelvis in 2-3 weeks to reassess iliopsoas muscle U/A C&S and serum albumin x one Ultra sound of thyroid to evaluate 1.6cm nodule CK x one Quantiferon TB Gold test- Test code 16603x times one Chest x-ray for evaluation of rales Echocardiogram to evaluate for endocarditis
Medications: Ceftriaxone/iso-osmotic 2 gm/50ml IV q 24 hours Diskitis/Osteomylitis Valacylovir HCL 1000mg po q 8 hours stops on 4/22/2014 HSV-1 and Zoster Therapies: Physical therapy Occupational therapy Instructions: Diet: High protein, regular, UMC Notify Np when ambulating well so Lovenox can be discontinued No heavy lifting, pushing, pulling or twisting
Call for temp> 99, SOB, Cough, Congestion, Pain not relieved by medication or SaO2<90%; high risk for infection due to splenectomy Second void residual due recent Foley discontinuation Incentive Spirometer QID Follow up: Ortho Consult with Dr. Destefano for ongoing evaluation of left shoulder in 2-3 weeks please call for an appointment 251-3100 Dr. Gehman infectious disease Primary care consult with Dr. Commisso for ongoing evaluation after short term rehabilitation
Clinical Key (2012) Osteomyelitis in Adults, retrieved from:https://www.clinicalkey.com/topics/orthopedic-surgery/osteomyelitis-in-adults.html Domino, F. (2014). The 5-minute clinical consult. (22nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. King, R.W. (2014) Medscape: Osteomyelitis in Emergency Medicine, Retrieved from: http://emedicine.medscape.com/article/785020-overview#a0199 http://emedicine.medscape.com/article/785020-overview#a0199 Mayoclinic (2014) Osteomyelitis, retrieved on 4/1/2014, Retrieved from: http://www.mayoclinic.org/diseases-conditions/osteomyelitis/basics/symptoms/CON- 20025518 Merriam-Webster (2014) Merriam- Webster Dictionary: Sequestram, retrieved from: http://www.merriam-webster.com/dictionary/sequestrum http://www.merriam-webster.com/dictionary/sequestrum Clinical Pharmacy (2014) Post Splenectomy Guidelines- Department of Clinical Pharmacy, retrieved from: http://clinicalpharmacy.ucsf.edu/idmp/ucsf_specific/postsplenectomy.htm Stolzfus, S. & Leonard, M. (2012) Health line: Dicitis, Retrieved from: http://www.healthline.com/health/diskitis#Overview Wood, C.J. (2014) Medscape: Streptococcus Group B Infections Differential Diagnoses, Retrieved from: http://emedicine.medscape.com/article/229091-differential
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