discharge documentation - himss 6/med_record_33_sid_45... · discharge documentation document name:...

Patient Name: DOB: Age/Sex: 58 years / Male Admitting: (INTE) MD, Attending: MD,

MR #: FIN #: Location:

Print Date: 14:19 of 143 Chart Request ID:

Discharge Documentation Document Name: Discharge Summary Document Status: Signed Performed By: MD, 16:39 EDT Authenticated By: MD, 13:59 EST Discharge Summary HIM Hospitalist Discharge Summary DATE OF ADMISSION: DATE OF DISCHARGE: PRIMARY CARE PHYSICIAN: Dr. RHEUMATOLOGIST: Triangle Arthritis and Rheumatology GASTROENTEROLOGIST: Dr. CONSULTING PHYSICIANS: 1. Infectious Disease service, Dr. 2. Dr. orthopedic surgery. FINAL DIAGNOSES: 1. Cellulitis and abscess of the left wrist and hand, status post incision and drainage caused by Methicillin resistant Staphylococcus aureus. 2. Rheumatoid arthritis. 3. Ulcerative colitis. 4. Gastroesophageal reflux disease. 5. Basal cell carcinoma and previous surgery for it. 6. History of cystectomy from the right buttock. DISCHARGE MEDICATIONS: 1. Oxycodone 5-10 mg q.4h. p.r.n. for severe pain, 30 tablets of 5 mg were provided. 2. Bactrim DS one tablet b.i.d. for 21 days. 3. Tylenol 1000 mg b.i.d. p.r.n. for pain. 4. Norco 5/325 mg one tablet q.6h. p.r.n. for moderate pain. 5. Vitamin D3 1000 international units daily. 6. Opti-Flex C 800 mg daily. 7. Citalopram 20 mg daily. 8. Opti-Flex G 1500 mg daily. 9. Mesalamine 1.5 grams daily in the morning. 10. Methotrexate 12.5 mg every Wednesday. 11. Remicade as per schedule. 12. Multivitamin one tablet daily. 13. Fish oil 1000 mg b.i.d. 14. Omeprazole 20 mg daily. DISCONTINUED MEDICATIONS: 1. Cephalexin. 2. Prednisone

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Discharge Documentation Document Name: Discharge Summary Document Status: Signed Performed By: MD, 16:39 EDT Authenticated By: MD, 13:59 EST CONDITION AT DISCHARGE: Stable and improved. FOLLOWUP: With Orthopedics on Thursday at 10:15 a.m. DISCHARGE INSTRUCTIONS: 1. Change dressing daily and as needed if soiled. 2. Call MD for temperature greater than 101.5, pain not relieved with medications, increased bleeding, nausea, vomiting, diarrhea, signs of infection, chills, night sweats or bleeding at surgical sites DISPOSITION: Home with family care. PROCEDURES PERFORMED: 1. Echocardiogram: Normal left ventricular size with mildly increased wall thickness. Normal systolic function with no obvious regional wall motion abnormalities. The estimated ejection fraction is 60-65%. Chordal SAM and mild LVOT gradient present of <20 mm HG. Septal E/E' ratio is 13.5 indicating normal filling pressure. The right ventricle is normal in size and function. The right atrium is normal in size. The left atrium is normal in size. Structurally normal mitral valve. Mild mitral regurgitation. No vegetations seen (suggest transesophageal echo if suspicion high). Aortic valve appears to be sclerotic without evidence of stenosis. No vegetations seen (suggest transesophageal echo if suspicion high). Normal appearance and motion of the tricuspid valve. Trace tricuspid regurgitation. No vegetations seen (suggest transesophageal echo if suspicion high). Pulmonic valve not well visualized. Mild pulmonic regurgitation. No vegetations seen (suggest transesophageal echo if suspicion high. Normal pericardium without effusion. IVC appears normal. Mild aortic dilatation at the level of the sinuses of valsalva (root). No evidence of endocarditis was noted. 2. MRI of the right hand initially without contrast and subsequently with contrast. This showed evidence of cellulitis with peripherally enhancing lobulated fluid collections dissecting along the dorsal superficial wrist and hand consistent with abscess formation. Myositis in the hypothenar compartment was also evident. Infectious inflammatory tenosynovitis was also suspected involving the flexor and extensor compartments. 3. Incision and drainage of abscess from the left hand and wrist by Dr. with Orthopaedics. Please see his operation note for complete details. There was no evidence of involvement of the tendon or the deep spaces of the hand/wrist. FINAL LABORATORY DATA: Culture from the abscess was consistent with MRSA. White blood cell count on 17th was 12.1, hemoglobin 13.5, platelets 149. Sodium 137, potassium 3.9, creatinine 0.82. HOSPITAL COURSE: Mr. was admitted from the emergency room where he presented with severe cellulitis of the left wrist. Clinically an abscess was suspected, MRI scan was done and subsequently orthopedics was consulted and an I and D was performed. Culture results showed MRSA. Vancomycin was continued throughout the hospital stay. Today his wound looks better. He has now been cleared by orthopedic surgery as well as infectious disease to be discharged on oral Bactrim for the next three weeks. Outpatient followup with orthopedic surgery was recommended as well as mentioned above. CC: MD

K MD

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Discharge Documentation Document Name: Discharge Summary Document Status: Signed Performed By: MD, 16:39 EDT Authenticated By: MD, 13:59 EST

16:39:16

DT: 10:46:01 /

cc: Copy2 Xtra MD; MD; ELECTRONICALLY REVIEWED AND SIGNED MD, ON: 13:59 ELECTRONICALLY SIGNED MD, ON: 13:59

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History and Physical Reports Document Name: History & Physical Document Status: Signed Performed By: (INTE) MD, 19:42 EDT Authenticated By: (INTE) MD, 19:49 EDT History & Physical HIM Hospitalist History and Physical DATE OF ADMISSION: REQUESTING PHYSICIAN: Dr. PRIMARY CARE PHYSICIAN: Dr. RHEUMATOLOGIST: At GASTROENTEROLOGIST: Dr. ADMITTING HOSPITALIST: Dr. CONSULTING ID PHYSICIAN: Infectious Disease Specialists. REASON FOR ADMISSION: Severe cellulitis. HISTORY OF PRESENT ILLNESS: Briefly, this is a 58-year-old gentleman with past medical history of rheumatoid arthritis, ulcerative colitis, and GERD who presents to the emergency room for the second time in 24 hours with cellulitis. The patient stated he had his initial dose of Remicade two weeks ago for both the rheumatoid arthritis and ulcerative colitis. One week later on Wednesday he developed a rash on his left hand. He describes it as initially a small "insect bite" that was very itchy. He did not scratch it with his nails but just rubbed it. By Thursday he noted that there was some swelling with some redness. By Sunday it really exploded in terms of the amount of swelling and redness that had occurred both on top of his hand, around the hand, and at the palmar aspect of his hand. He came to the emergency room yesterday to get it evaluated after he had seen the primary care physician. He did not have any constitutional symptoms with any fevers, chills, or rigors at that time. They noted that he was having a scab lesion on the lateral dorsal surface with erythema and swelling of the entire dorsal surface of the hand as well as proximal spreading in a linear fashion on the volar surface of the forearm. There was no evidence of compartment syndrome. He was given a dose of 1 gram of vancomycin IV, and he was discharged with 500 mg of Keflex and double strength Bactrim. Yesterday evening while returning back home, he developed some chills, and then today he continued to have intermittent chills. He had taken two doses of Septra and three of Keflex by this time. He re-presents to the emergency room for concerns of worsening infection. The patient denies having any objective fevers but does have chills and rigors. He does state that he has been flushed. Denies having any chest pain, palpitations, orthopnea, PND, lower extremity edema, shortness of breath, dyspnea on exertion, headaches, change in vision or hearing, lightheadedness, syncopal episodes, nausea, vomiting, abdominal pain, or diarrhea. The patient denies having any prior history of skin infections. No known recent trauma. He has been otherwise healthy and has remained outside of the hospital in terms of illnesses. In the emergency room, he received 1.5 grams of vancomycin and 3.375 mg of IV Zosyn. We were consulted for admission. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Ulcerative colitis. 3. GERD. 4. Basal cell carcinoma, status post excision. 5. Cystectomy from his right buttock. HOME MEDICATIONS:

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History and Physical Reports Document Name: History & Physical Document Status: Signed Performed By: (INTE) MD, 19:42 EDT Authenticated By: (INTE) MD, 19:49 EDT 1. Remicade IV. 2. Citalopram 20 daily. 3. Apriso 1.5 grams q.a.m. 4. Methotrexate 12.5 q. Wednesdays. 5. Multivitamin daily. 6. Prednisone taper. ALLERGIES: ALMONDS. SOCIAL HISTORY: The patient lives with his two dogs. No alcohol or tobacco. Drives an 18 wheeler. FAMILY HISTORY: Father with tobacco and lung cancer. Mother and brother with atrial fibrillation. REVIEW OF SYSTEMS: As per HPI, otherwise 12-point review of systems otherwise negative. PHYSICAL EXAMINATION: VITAL SIGNS: T-max of 37.4, blood pressure 136/72-125/73, heart rate 72-91, respiratory rate 20, O2 saturation 98% on room air. GENERAL: The patient is well-developed, well-nourished, pleasant, appears flushed. He is awake, alert and oriented to person, place and time, in no apparent distress. HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive. Extraocular movements are intact. Oropharynx is clear. Anicteric sclerae. NECK: Supple, without lymphadenopathy. Carotid pulses are 2+. JVP is flat. PULMONARY: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi. CARDIOVASCULAR: Regular rate. Positive S1, S2. Systolic ejection murmur heard at the apex. ABDOMEN: Positive bowel sounds, soft, nondistended, nontender. No rebound or guarding. EXTREMITIES: No cyanosis or clubbing in the extremities. Left upper extremity shows significant swelling over the plantar and dorsal aspect of his hand as well as his forearm. There is lymphangitic spreading with erythema along the underside of his upper arm. His radial and ulnar pulses are palpable. He has movement of his fingers and good sensation throughout. There is a 1 x 1 scab on the lateral aspect of the dorsum of the left hand, which is likely the inciting source. No obvious crepitus or fluctuance is noted. There is no evidence of splinter hemorrhaging. NEUROLOGIC: Moving all 4 extremities. Sensation intact to light touch. No focal deficits. PERTINENT LABORATORY DATA: WBC 12.2, down from 13.3, hematocrit 39.7, platelets 148, neutrophils 83%. Chem-7 normal. IMPRESSION AND PLAN: Briefly, this is a 58-year-old gentleman who is immunocompromised on Remicade for his rheumatoid arthritis and ulcerative colitis who is now presenting with failed outpatient therapy of cellulitis of his left hand and forearm. The patient does not meet criteria for SIRS or sepsis at this time. He also has what we presume may be a new murmur as he has never been told that he has one. The patient will be admitted for further workup and treatment. 1. Cellulitis. Blood cultures have been obtained from ER visit today. There were no blood cultures obtained from his ER visit yesterday. Follow up the blood cultures. I have marked his line of demarcation of erythema with surgical marker. Keep his left arm elevated above his heart. Continue IV vancomycin. Will consult pharmacy for dosing. Continue IV Zosyn. Infectious disease specialist consult in the morning. Monitor for compartment syndrome. 2. Cardiac murmur. Will obtain a transthoracic echocardiogram. May need TEE. 3. Ulcerative colitis. Continue Apriso and prednisone.

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History and Physical Reports Document Name: History & Physical Document Status: Signed Performed By: (INTE) MD, 19:42 EDT Authenticated By: (INTE) MD, 19:49 EDT 4. Rheumatoid arthritis. Continue methotrexate. 5. Anxiety. Continue citalopram. 6. Gastrointestinal prophylaxis with Pepcid as needed. 7. Deep venous thrombosis prophylaxis with compressive devices for now. 8. CODE STATUS: FULL.

MD

DD: 19:42:05 DT: 20:47:18

/ cc: MD; MD ELECTRONICALLY REVIEWED AND SIGNED (INTE) MD, ON: 19:49 ELECTRONICALLY SIGNED (INTE) MD, ON: 19:49

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Consultation Notes Document Name: Consultation Note Document Status: Signed Performed By: (ORTH) MD, 21:46 EDT Authenticated By: (ORTH) MD, 13:25 EDT Consultation Note HIM Consultation Report DATE OF CONSULTATION: REASON FOR CONSULTATION: Left hand cellulitis. REQUESTING PHYSICIAN: Dr. HISTORY OF PRESENT ILLNESS: Mr. is a 58-year-old male admitted to Hospital back on . This was for cellulitis, left upper extremity. He received a 1st dose of Remicade approximately 2 weeks ago at his rheumatologist's office through a peripheral in his left wrist. This was an uneventful infusion, and the IV line was discontinued. After about a week following the Remicade infusion, the patient developed redness in the ulnar aspect of the left wrist. Initially it was described as a pimple. The patient then experienced progressive swelling and pain to the point that it he has spreading redness and tenderness. Visited the emergency room on He was given a dose of IV vancomycin. He was advised admission; however, the patient ultimately wanted to be discharged home on p.o. Keflex and p.o. Bactrim. The patient took these antibiotics and came back to the emergency room on with spreading lymphangitis, erythema. In the ER, he had a temperature of 37.4. Ultimately, he has been in the hospital now for 2 days. He has been on IV antibiotics. He does feel like he is getting better. He does feel like it is improving. PAST MEDICAL HISTORY: Rheumatoid arthritis, ulcerative colitis, and GERD. PAST SURGICAL HISTORY: Basal cell carcinoma removed from the face, cyst removal right buttock. He is on methotrexate every Wednesday as well as on a prednisone taper. CURRENT MEDICATIONS: IV antibiotics. Specifically, he is currently on vancomycin. FAMILY HISTORY: Significant for lung cancer in his father. SOCIAL HISTORY: Drives an 18-wheel truck. He is single, no children. No history of tobacco or alcohol use. No recent history of sexual activity. PHYSICAL EXAMINATION: CURRENT VITAL SIGNS: His temperature was 36.7, blood pressure 130/63, pulse 79, respiratory rate 16, satting 97% on room air. GENERAL: Well-appearing male, alert and oriented x3. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation. ABDOMEN: Soft, nontender. EXTREMITIES: Ulnar aspect of the left upper extremity does have a scab. There is an area of erythema extending over the dorsum of the hand. He has no tenderness on the volar surface of the hand. He is able to make a fist currently. He is able to fully

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Consultation Notes Document Name: Consultation Note Document Status: Signed Performed By: (ORTH) MD, 21:46 EDT Authenticated By: (ORTH) MD, 13:25 EDT straighten his fingers. He has no tenderness over the flexor tendon or the extensor tendons in the fingers. He has no pain with passive extension of the fingers. He has full range of motion of the elbow. He is noted to have some mild erythema. It does not go past the elbow currently. There is no streaking. He is neurovascularly intact distally. Review of the MRI which was obtained on reveals cellulitis with peripheral enhancing lobulated fluid collection dissecting along the dorsal superficial wrist and hand, likely cellulitis with an abscess formation. There does appear to be evidence of inflammation along the flexor and extensor compartments and myositis in the hypothenar compartments. ASSESSMENT AND PLAN: This patient is a very pleasant male who comes in with 2 days of basically left hand cellulitis. I do think he has a small abscess. I do want to continue IV antibiotics. He has actually gotten significantly better over the past 2 days per the patient. He does not have any evidence clinically of involvement of the tendons. Specifically, he has no pain with passive extension of his fingers. He has no pain along the flexor or extensor surfaces, and really has no involvement of his fingers. At this point, I do think he is going to need an irrigation and debridement. We did discuss with the patient doing it either tonight or tomorrow. He would rather wait and do it tomorrow morning which I do not see harm in, given the fact that he has gotten better progressively over the past 2 days. Therefore, will get him set up for surgery tomorrow for a left wrist irrigation and debridement. This will be a drainage of this abscess. Will need to continue IV antibiotics. I will have my partner follow him over the weekend. All of his questions were answered.

U MD

DD: 21:46:13 DT: 23:05:16

/ 3 cc: MD; ELECTRONICALLY REVIEWED AND SIGNED (ORTH) MD, ON: 13:25 ELECTRONICALLY SIGNED (ORTH) MD, ON: 13:25

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Consultation Notes Document Name: Consultation Note Document Status: Signed Performed By: (INFE) MD, 12:15 EDT Authenticated By: (INFE) MD, 12:35 EDT Consultation Note HIM Consultation Report DATE OF CONSULTATION: PHYSICIAN REQUESTING CONSULT: Dr. REASON FOR CONSULTATION: Left hand cellulitis. HISTORY OF PRESENT ILLNESS: Mr. is a 58-year-old male who was admitted to Hospital on . This patient received his first dose of Remicade approximately 2 weeks ago at his rheumatologist's office through a peripheral IV in his right wrist. This was an uneventful infusion and the IV line was discontinued after that. About a week following Remicade infusion, the patient developed redness on the ulnar aspect of his left wrist. Initially, the patient had what he describes as a pimple and he describes having tried to rub this pimple off which led to a scab forming on the ulnar aspect of the left wrist. The patient then experienced progressive swelling and pain to the point that he had spreading redness and tenderness which prompted a visit to the emergency room on . In the ER, the patient was given a dose of IV vancomycin. He was advised admission. However, the patient had to care for his animals at home and hence was discharged home on p.o. Keflex and p.o. Bactrim. The patient took a few doses of these antibiotics but did not notice any improvement and hence came back to the emergency room for a second time on . By this time, he was noted to have spreading lymphangitis and erythema both on the medial aspect of his forearm as well as some erythema in his arm. In the ER, he had a temperature of 37.4, pulse of 91, blood pressure 126/64. By this time the patient could not make a fist with his left hand. He did report some fevers at home. No chills, no sweats. No cough, sore throat, sputum production, or hemoptysis. No chest pain or palpitations. No abdominal pain, nausea, vomiting or diarrhea. No dysuria, hematuria, increased frequency. No new skin rashes. No real joint pain in the wrist or in the elbow. He does not report any neurological symptoms such as headaches, seizures, unilateral weakness, speech or visual symptoms. PAST MEDICAL HISTORY: Rheumatoid arthritis as well as ulcerative colitis.At home he was noted to be on methotrexate every Wednesday as well as on prednisone taper. The patient has GERD. PAST SURGICAL HISTORY: Significant for basal cell carcinoma status post excision from the face, cyst removal from his right buttock. CURRENT MEDICATIONS: IV antibiotics in the hospital include IV vancomycin and IV Zosyn. The patient is on a prednisone taper in the hospital. He is also on Celexa, Colace, mesalamine, multivitamin, Protonix. FAMILY HISTORY: Significant for lung cancer in his father.

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Consultation Notes Document Name: Consultation Note Document Status: Signed Performed By: (INFE) MD, 12:15 EDT Authenticated By: (INFE) MD, 12:35 EDT SOCIAL HISTORY: The patient drives an 18-wheeler truck within . He is single. He has no children. He keeps dogs as pets at home. There is no history of tobacco or alcohol use. There is no history of recreational use. There is no history of recent sexual activity. The patient is MSW. REVIEW OF SYSTEMS: Per history of present illness. Rest of 14-point review of systems is negative. PHYSICAL EXAMINATION: VITAL SIGNS: Maximum temperature is 37.5, current temperature is 37.5, pulse is 82, blood pressure is 104/57. GENERAL: Reveals a 58-year-old male who is in no apparent distress. HEENT: Does not reveal any pallor, icterus, or lymphadenopathy. Oral hygiene is good. CARDIOVASCULAR: Heart sounds 1 and 2 are heard, very faint ejection systolic murmur heard best at the right upper sternal border. CHEST: Reveals equal air entry bilaterally with no added sounds. ABDOMEN: Noted to be soft, nontender, no masses or organomegaly appreciated. Bowel sounds active. EXTREMITIES: Show no cyanosis or clubbing. Left upper extremity was examined. On the ulnar aspect of the left upper extremity is noted a scab. From the scab emanates significant area of erythema that extends on the dorsal aspect of the hand. The entire volar aspect of the hand is also swollen. This is quite tender to palpate. The patient is unable to make a fist. He is also unable to straighten his fingers completely. Examining the left forearm, the patient does have streaks of erythema that are noted on the medial aspect and this extends all the way up into the elbow. The right upper extremity does not show any evidence of erythema. No cyanosis or clubbing noted. SKIN: Does not reveal any other major rashes. NEUROLOGIC: No major cranial nerve deficits are noted. The patient is able move all 4 extremities. LABORATORY DATA: This patient shows a white count 12.1, down from 13.3. Hemoglobin of 13.5, hematocrit 37.8, platelet count of 149. Sodium is 137, potassium 3.7, BUN is 10, creatinine is 0.8. Blood cultures x2 sets from show no growth to date. No radiology data on this patient at this time. ASSESSMENT AND PLAN: Mr. is a 58-year-old male with what appears to be quite a significant area of swelling and likely abscess formation in the dorsal aspect of his hand and possibly in the volar aspect of his hand as well. I wonder if he has a flexor tenosynovitis and I wonder if this is all community-associated MRSA infection. The plan here would be to stop his Zosyn and continue vancomycin. Will order an MRI of the left hand and the left forearm. I have also requested Dr. to obtain hand surgery consultation as I do believe that this is most likely going to need an incision and drainage procedure. An echo has been ordered already on this patient. I highly doubt whether this patient has endocarditis. Will follow this patient with you. Thank you for this consult.

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Consultation Notes Document Name: Consultation Note Document Status: Signed Performed By: (INFE) MD, 12:15 EDT Authenticated By: (INFE) MD, 12:35 EDT

MD

DD: 12:15:06 DT: 17:01:16

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Physician - Surgical/Procedure Documentation Document Name: Anesthesia Progress Notes Document Status: Signed Performed By: (ANES) MD, 20:11 EDT Authenticated By: (ANES) MD, 20:11 EDT Anesthesia Assessment Entered On: 20:13 EDT Anesthesia Assessment Entered On: 20:13 EDT Anesthesia Assessment Entered On: 20:13 EDT Anesthesia Assessment Entered On: 20:13 EDT

Performed On: 20:11 EDT b Performed On: 20:11 EDT b Performed On: 20:11 EDT b Performed On: 20:11 EDT by (ANES) MD, y (ANES) MD, y (ANES) MD, y (ANES) MD, Procedure Procedure Procedure Procedure Procedure to be Performed : I and D left wrist Height : 75.00in(Converted to: 6ft 3in, 190.50cm, 6.25ft) Height (cm) : 190.5cm Dosing Weight : 88.100kg(Converted to: 194lb 4oz, 194.227lb, 3,107.636oz) Method of Obtaining Weight : Actual Body Mass Index : 24.28m2 Body Surface Area : 2.16 NPO Comments : advised NPO mn

(ANES) MD, - 20:11 EDT Allergy Allergy Allergy Allergy Allergies Reviewed : Yes

(ANES) MD, - 20:11 EDT Allergies (Active) ALMONDS Estimated Onset Date: Unspecified ; Reactions: itching of the

throat ; Created By: RN, ; Reaction Status: Active ; Category: Drug ; Substance: ALMONDS ; Type: Allergy ; Updated By: RN, Source: Patient ; Reviewed Date: 22:06 EDT

Med List Med List Med List Med List Meds Reviewed : Yes

(ANES) MD, - 20:11 EDT Medication List Normal Order NS 1,000 mL : NS 1,000 mL ; Status: Ordered ; Ordered As Mnemonic:

Sodium Chloride 0.9% 1,000 mL ; Simple Display Line: 100 mL/hr, IVD, Stop: 19:18:00 EDT ; Ordering Provider:

(INTE) MD, Catalog Code: Sodium Chloride 0.9% ; Order Dt/Tm: 19:19:24

predniSONE 10mg tab : predniSONE 10mg tab ; Status: Canceled ; Ordered As

Mnemonic: Deltasone ; Simple Display Line: 10 mg, 1 tab, PO, daily ; Ordering Provider: Jr., (INTE) MD, Catalog Code: predniSONE ; Order Dt/Tm: 21:06:49 ; Comment: Thur= 10 mg

gadopentetate dimeglumine 46.9% sol

: gadopentetate dimeglumine 46.9% sol ; Status: Completed ; Ordered As Mnemonic: Gadolinium ; Simple Display Line: 18 mL, IV, once ; Ordering Provider: Jr. (RAD) MD, Catalog Code: gadopentetate dimeglumine ; Order Dt/Tm:

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11:18:17 ; Comment: For use in Radiology procedure For use in Radiology Procedure

predniSONE 10mg tab : predniSONE 10mg tab ; Status: Discontinued ; Ordered As

Mnemonic: Deltasone ; Simple Display Line: 15 mg, 1.5 tab, PO, daily ; Ordering Provider: Jr., (INTE) MD, Catalog Code: predniSONE ; Order Dt/Tm: 21:06:49 ; Comment: Wed=15 mg

predniSONE 5mg tab : predniSONE 5mg tab ; Status: Discontinued ; Ordered As

Mnemonic: Deltasone ; Simple Display Line: 5 mg, 1 tab, PO, daily ; Ordering Provider: Jr., (INTE) MD, Catalog Code: predniSONE ; Order Dt/Tm: 21:06:49 ; Comment: fri=5 mg

vancomycin : vancomycin ; Status: Discontinued ; Ordered As Mnemonic:

Vancocin HCl ; Simple Display Line: 2,000 mg, 250 mL/hr, IVPB, q12h (i) ; Ordering Provider: (INTE) MD, Catalog Code: vancomycin ; Order Dt/Tm: 20:22:48 ; Comment: start stacked dose 8 hours after ED dose, then q12 subsequently pH 3-5

vancomycin : vancomycin ; Status: Ordered ; Ordered As Mnemonic:

Vancocin HCl ; Simple Display Line: 1,250 mg, 166.67 mL/hr, IVPB, q8h ; Ordering Provider: (INTE) MD, Catalog Code: vancomycin ; Order Dt/Tm: 16:00:40 ; Comment: Pharmacy consult pH 3-5

pantoprazole 40mg EC tab : pantoprazole 40mg EC tab ; Status: Ordered ; Ordered As

Mnemonic: Protonix ; Simple Display Line: 40 mg, 1 tab, PO, daily ; Ordering Provider: (INTE) MD, Catalog Code: pantoprazole ; Order Dt/Tm: 21:17:00 ; Comment: THERAPEUTIC SUBSTITUTION FOR omeprazole do not crush

citalopram 20mg tab : citalopram 20mg tab ; Status: Ordered ; Ordered As

Mnemonic: CeleXA ; Simple Display Line: 20 mg, 1 tab, PO, daily ; Ordering Provider: (INTE) MD, Catalog Code: citalopram ; Order Dt/Tm: 21:16:28

mesalamine 1.2 gm EC tablet : mesalamine 1.2 gm EC tablet ; Status: Ordered ; Ordered As

Mnemonic: Lialda ; Simple Display Line: 2.4 gm, 2 tab, PO, qam ; Ordering Provider: (INTE) MD, Catalog Code: mesalamine ; Order Dt/Tm: 21:16:01 ; Comment: THERAPEUTIC SUBSTITUTION FOR Apriso 1.5 gm

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HYDROcodone/apap 5-325mg tab

: HYDROcodone/apap 5-325mg tab ; Status: Ordered ; Ordered As Mnemonic: Norco 325 mg-5 mg oral tablet ; Simple Display Line: 1 tab, PO, q6h, PRN: Pain, mild-moderate ; Ordering Provider: (INTE) MD, Catalog Code: acetaminophen-hydrocodone ; Order Dt/Tm: 21:17:31 ; Comment: "NOT TO EXCEED 4 GRAMS ACETAMINOPHEN IN 24 HOURS"

multivitamin tab : multivitamin tab ; Status: Ordered ; Ordered As Mnemonic:

Theragran ; Simple Display Line: 1 tab, PO, daily ; Ordering Provider: (INTE) MD, Catalog Code: multivitamin ; Order Dt/Tm: 20:55:00

oxyCODONE-acetaminophen 5-325mg tab

: oxyCODONE-acetaminophen 5-325mg tab ; Status: Ordered ; Ordered As Mnemonic: Percocet 5mg-325mg oral tablet ; Simple Display Line: 1-2 tab, PO, q6h, PRN: Pain, moderate ; Ordering Provider: (INTE) MD, Catalog Code: acetaminophen-oxycodone ; Order Dt/Tm: 20:30:10 ; Comment: PRN reason modified per policy "NOT TO EXCEED 4 GRAMS ACETAMINOPHEN IN 24 HOURS"

docusate sodium 100mg cap : docusate sodium 100mg cap ; Status: Ordered ; Ordered As

Mnemonic: Colace ; Simple Display Line: 100 mg, 1 cap, PO, daily ; Ordering Provider: (INTE) MD, Catalog Code: docusate ; Order Dt/Tm: 20:30:20

acetaminophen 650mg supp : acetaminophen 650mg supp ; Status: Ordered ; Ordered As

Mnemonic: Tylenol ; Simple Display Line: 650 mg, 1 supp, rectal, q4h, PRN: Pain / Temperature >101 ; Ordering Provider:

(INTE) MD, Catalog Code: acetaminophen ; Order Dt/Tm: 19:20:24 ; Comment: NOT TO EXCEED 4GM ACETAMINOPHEN IN 24HRS

ondansetron 2mg/ml inj 2ml : ondansetron 2mg/ml inj 2ml ; Status: Ordered ; Ordered As

Mnemonic: Zofran ; Simple Display Line: 4 mg, 2 mL, IV, q6h, PRN: Nausea / Vomiting ; Ordering Provider: (INTE) MD, Catalog Code: ondansetron ; Order Dt/Tm:

19:20:25

acetaminophen 325mg tab : acetaminophen 325mg tab ; Status: Ordered ; Ordered As

Mnemonic: Tylenol ; Simple Display Line: 650 mg, 2 tab, PO, q4h, PRN: Pain / Temperature >101 ; Ordering Provider:

(INTE) MD, Catalog Code: acetaminophen ; Order Dt/Tm: 19:20:24 ; Comment: NOT TO EXCEED 4GM ACETAMINOPHEN IN 24HRS

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Physician - Surgical/Procedure Documentation Document Name: Anesthesia Progress Notes Document Status: Signed Performed By: (ANES) MD, 20:11 EDT Authenticated By: (ANES) MD, 20:11 EDT Home Meds sulfamethoxazole-trimethoprim : sulfamethoxazole-trimethoprim ; Status: Documented ;

Ordered As Mnemonic: Septra DS 800 mg-160 mg oral tablet ; Simple Display Line: 1 tab, PO, bid, 20 tab ; Catalog Code: sulfamethoxazole-trimethoprim ; Order Dt/Tm: 18:06:51 ; Comment: started for 10 days

acetaminophen-hydrocodone : acetaminophen-hydrocodone ; Status: Documented ;

Ordered As Mnemonic: Norco 325 mg-5 mg oral tablet ; Simple Display Line: 1 tab, PO, q6h, PRN: as needed for pain ; Catalog Code: acetaminophen-hydrocodone ; Order Dt/Tm:

18:03:30

omeprazole : omeprazole ; Status: Documented ; Ordered As Mnemonic:

omeprazole 20 mg oral enteric coated tablet ; Simple Display Line: 20 mg, PO, daily, 30 tab ; Catalog Code: omeprazole ; Order Dt/Tm: 18:02:36

cephalexin : cephalexin ; Status: Documented ; Ordered As Mnemonic:

cephalexin ; Simple Display Line: 500 mg, PO, q6h ; Catalog Code: cephalexin ; Order Dt/Tm: 17:18:22 ; Comment: started for 10 days

Misc Prescription : Misc Prescription ; Status: Documented ; Ordered As

Mnemonic: Remicaid ; Catalog Code: Misc Prescription ; Order Dt/Tm: 17:53:49

chondroitin : chondroitin ; Status: Documented ; Ordered As Mnemonic:

OptiFlex-C ; Simple Display Line: 800 mg, PO, daily ; Catalog Code: chondroitin ; Order Dt/Tm: 17:51:18

glucosamine : glucosamine ; Status: Documented ; Ordered As Mnemonic:

Optiflex-G ; Simple Display Line: 1,500 mg, PO, daily ; Catalog Code: glucosamine ; Order Dt/Tm: 17:51:13

acetaminophen : acetaminophen ; Status: Documented ; Ordered As

Mnemonic: acetaminophen ; Simple Display Line: 1,000 mg,

Patient Name: MR #:

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Page 25 of 143

PO, bid, PRN: as needed for pain ; Catalog Code: acetaminophen ; Order Dt/Tm: 17:51:25

cholecalciferol : cholecalciferol ; Status: Documented ; Ordered As

Mnemonic: Vitamin D3 1000 intl units oral tablet ; Simple Display Line: 1,000 IntUnit, 1 tab, PO, daily ; Catalog Code: cholecalciferol ; Order Dt/Tm: 1 17:51:06

citalopram : citalopram ; Status: Documented ; Ordered As Mnemonic:

citalopram 20 mg oral tablet ; Simple Display Line: 20 mg, 1 tab, PO, daily ; Catalog Code: citalopram ; Order Dt/Tm:

17:50:08

mesalamine : mesalamine ; Status: Documented ; Ordered As Mnemonic:

Apriso 0.375 g oral capsule, extended release ; Simple Display Line: 1.5 gm, 4 cap, PO, qam ; Catalog Code: mesalamine ; Order Dt/Tm: 17:50:01

omega-3 polyunsaturated fatty acids

: omega-3 polyunsaturated fatty acids ; Status: Documented ; Ordered As Mnemonic: Fish Oil 1000 mg oral capsule ; Simple Display Line: 1,000 mg, 1 cap, PO, bid ; Catalog Code: omega-3 polyunsaturated fatty acids ; Order Dt/Tm:

17:50:52

predniSONE : predniSONE ; Status: Documented ; Ordered As Mnemonic:

predniSONE 5 mg oral tablet ; Simple Display Line: 6tabs, PO, daily ; Catalog Code: predniSONE ; Order Dt/Tm: 17:49:52 ; Comment: 5 tabs on mon 4 on tue 3 on wed, 2 on thurs, 1 on fri

multivitamin : multivitamin ; Status: Documented ; Ordered As Mnemonic:

multivitamin ; Simple Display Line: 1 tab, PO, daily ; Catalog Code: multivitamin ; Order Dt/Tm: 10:46:38

methotrexate : methotrexate ; Status: Documented ; Ordered As Mnemonic:

methotrexate ; Simple Display Line: 12.5 mg, PO, Wed ; Catalog Code: methotrexate ; Order Dt/Tm: 10:46:38

General Info General Info General Info General Info Pregnancy Status : N/A Anesthesia/Transfusions : Patient denies prior anesthesia/transfusion reaction

Patient Name: MR #:

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Physician - Surgical/Procedure Documentation Document Name: Anesthesia Progress Notes Document Status: Signed Performed By: (ANES) MD, 20:11 EDT Authenticated By: (ANES) MD, 20:11 EDT Languages : English

(ANES) MD, - 20:11 EDT Health History I Health History I Health History I Health History I Cardiovascular History : DENIES Respiratory History : DENIES Gastrointestinal History : Reflux Disease, Other Gastrointestinal History Comments : ULCERATIVE COLITIS Genitourinary History : Kidney Stones Endocrine/Metabolic History : DENIES

(ANES) MD, - 20:11 EDT Health History II Health History II Health History II Health History II Neurological History : DENIES Psychiatric History : DENIES Oncologic History : Skin Cancer Immunologic History : DENIES Musculoskeletal History : Rheumatoid Arthritis Ocular Auditory Speech History : DENIES Ocular Auditory Speech Devices : Wears Glasses Integumentary History : DENIES

(ANES) MD, - 20:11 EDT Health History III Health History III Health History III Health History III Oncologic Procedure History : Skin cancer removal Medical Equipment : None

(ANES) MD, - 20:11 EDT Social Habits Social Habits Social Habits Social Habits Alcohol Use : None Smoking Status : Never smoked Exposure to Tobacco Smoke : No known exposure Drug Use : None

(ANES) MD, - 20:11 EDT PostPostPostPost----op Nausea Vomiting Assmt op Nausea Vomiting Assmt op Nausea Vomiting Assmt op Nausea Vomiting Assmt Nausea/Vomiting Post Prev Surg Score : 0 Neurological Health History Score : 0 Non Smoking Score : Yes Nausea Vomiting Risk Score : 1

(ANES) MD, - 20:11 EDT PrePrePrePre----Anesthesia Assessment Anesthesia Assessment Anesthesia Assessment Anesthesia Assessment Anesthesia History : Prior anesthesia Family History of Anesthesia : No known anesthesia problems Dental Risks Discussed : No MP : 2 Mouth Opening : Good Neck Extension : Good ASA Physical Status : 3 Anesthesia Plan : Supraclavicular Block Anesthesia Plan Comments : cellulitis appears localized to wrist and hand. R/B/I of SC block discussed, including bleeding, infection, and nerve damage. Wishes to proceed.

Patient Name: MR #:

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Physician - Surgical/Procedure Documentation Document Name: Anesthesia Progress Notes Document Status: Signed Performed By: (ANES) MD, 20:11 EDT Authenticated By: (ANES) MD, 20:11 EDT Risks, Benefits, Alternatives Discussed with Patient / Family : Yes

(ANES) MD, - 20:11 EDT

Patient Name: MR #:

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Physician - Surgical/Procedure Documentation Document Name: Operative/Procedure Report Document Status: Signed Performed By: (ORTH) MD, 14:01 EDT Authenticated By: (ORTH) MD, 12:51 EDT Operative/Procedure Report HIM Operative Report DATE OF SERVICE: PREOPERATIVE DIAGNOSIS: Left wrist and hand abscess. POSTOPERATIVE DIAGNOSIS: Left wrist and hand abscess. PROCEDURE PERFORMED: Incision and drainage of abscess. SURGEON: M.D. ANESTHESIA: Monitored anesthesia care and local block. COMPLICATIONS: None. SPECIMENS: Aerobic, anaerobic, and mycobacterial cultures of grossly purulent fluid. INDICATIONS FOR SURGERY: Mr. is a 58-year-old gentleman who has a draining abscess along the ulnar aspect of the left wrist. He presents today for formal incision and drainage, understanding risks, benefits, and alternatives of surgery. Risks of surgery including bleeding, infection, pain, damage to surrounding structures, nonhealing wound, continued infection, poor functional outcome, and possible need for repeat surgery were discussed. DESCRIPTION OF PROCEDURE: The patient was identified in the preop holding area and the correct operative site was marked. He was brought back to the OR suite and positioned supine on the table. A well-padded tourniquet was placed on the upper arm. Monitored anesthesia care was induced. A nerve block was done along the ulnar aspect of the forearm with local anesthetic solution containing equal parts of 0.5% Marcaine and 1% lidocaine. The extremity was then prepped and draped in standard sterile surgical fashion. The extremity was exsanguinated and tourniquet inflated. There were couple of draining sinuses along the ulnar aspect of the wrist at the level of the ulnar neck. I made a longitudinal incision which incorporated these draining sinuses along the central aspect. There was a large amount of thick yellow pus within the subcutaneous tissue. The dorsal sensory branches of the ulnar nerve were identified and protected. The abscess tracked within the subcutaneous tissue plane along the dorsal ulnar aspect of the hand. A second longitudinal incision was therefore made at the level of the fourth metacarpal neck. Skin edges around the abscessed sinuses were debrided. Liquified fat and purulent material was debrided as well. Three liters of saline containing bacitracin were then flushed through the abscess cavity using a pulsatile lavage. I then incised the distal edge of the retinaculum in order to inspect the extensor tendons. There was a serous thin fluid around the tendon, but no gross purulence. The fourth through sixth compartments were inspected. Another 3 liters of saline containing bacitracin was then irrigated through the abscess cavity. This was followed by 3 liters of plain saline using pulsatile lavage. The wounds were then closed loosely with 3-0 nylon. A Penrose drain had been placed with one limb exiting through each of the wounds. A dry gauze dressing and volar splint was applied. The tourniquet was deflated. The fingers had brisk capillary refill. The patient was taken to the recovery room in stable condition. DISPOSITION: The patient will continue with empiric IV antibiotics per infectious disease and the medical team. Tomorrow the dressing will be changed. He will be fitted with a volar splint. The Penrose drain will be removed. He will have a dry dressing

Patient Name: MR #:

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Physician - Surgical/Procedure Documentation Document Name: Operative/Procedure Report Document Status: Signed Performed By: (ORTH) MD, 14:01 EDT Authenticated By: (ORTH) MD, 12:51 EDT changed daily at that point. If the wound seems to be stabilizing over the weekend, I suspect he may be discharged at that point, pending final infectious disease recommendations.

MD

DD: 14:01:23 DT: 15:02:12

/ ELECTRONICALLY REVIEWED AND SIGNED (ORTH) MD, ON: 12:51 ELECTRONICALLY SIGNED (ORTH) MD, ON: 12:51

Patient Name: MRN: FIN: Facility: Page Number: 31


Document Name: ED Note-Physician Document Status: Signed Performed By: (EMER) MD, 18:18 EDT Authenticated By: (EMER) MD, 14:42 EDT ED Note-Physician ED Emergency Room Report DATE OF SERVICE: DATE OF BIRTH: CHIEF COMPLAINT: Worsening infection. HISTORY OF PRESENT ILLNESS: Mr. is a pleasant 58-year-old male who was seen here last night with what he thought was a bug bite on his left arm. He had IV antibiotics last night and was offered admission but decided after discussion to go home and try oral antibiotics. However, since the patient has gone home, he has had increased swelling of his hand, wrist and arm. He also now has red streaks going further up his arm towards his axilla. He has had some chills at home as well. Denies nausea, vomiting. States his appetite has been good. However, as he is obviously getting worse, he came back in today for further evaluation. PAST MEDICAL HISTORY: The patient has a history of rheumatoid arthritis on methotrexate and Remicade. He does not have diabetes. He has reflux, ulcerative colitis. MEDICATIONS: Glucosamine, Tylenol, chondroitin, cholecalciferol, fish oil, B12, mesalamine, prednisone, citalopram, esomeprazole, Norco, cephalexin, Bactrim, multivitamin and folate, methotrexate once a week, Remicade that he last got 2 weeks ago. ALLERGIES: No known drug allergies, but he is allergic to ALMONDS. SOCIAL HISTORY: The patient is here with family. PCP is Dr. He works full-time. He is divorced and lives in ,

. REVIEW OF SYSTEMS: Negative except as noted in history of present illness. PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 37.4, blood pressure 126/64, pulse 91, respirations 20, pulse 97% on room air. GENERAL: The patient is awake, alert, answers questions appropriately, not in any acute cardiac or respiratory distress. HEENT: Head shows no evidence of any trauma. Sclerae are anicteric. Oropharynx is clear, without any erythema. Mucous membranes are moist. NECK: Shows no lymphadenopathy, no rigidity, no obvious JVD. CARDIAC: Regular with S1, S2. He has a 2-3/6 systolic murmur. LUNGS: Clear bilaterally. CHEST WALL: Nontender. ABDOMEN: Soft, nontender, nondistended with positive bowel sounds. EXTREMITIES: Left upper extremity shows significant redness at the ulnar aspect of the left wrist, actually just distal to the wrist joint over the area of the base of the fifth metacarpal. There is a 0.5 cm x 1 cm scab there where he had scratched the wound earlier. There is a lot of surrounding redness in that area. He has swelling to all his fingers, but good capillary refill. He is able to flex and extend the wrist a little bit but does have pain with doing that. He has the same pain with ulnar and radial deviation. He has swelling going up his forearm, redness going up his forearm and red streaks going up the volar aspect of his forearm as well. LABORATORY WORK: Blood cultures are pending. Labs from yesterday show a white count 13.3 with 76% neutrophils, hemoglobin 14.1, hematocrit 41.3, platelets 157. Sodium 141, potassium 3.9, chloride 106, bicarbonate 27, BUN 12, creatinine 0.68, glucose is 82. Calcium is 8.8. EMERGENCY DEPARTMENT COURSE: The patient is interviewed and examined as noted above. IV access established. Labs were obtained. Blood cultures were obtained x2. The patient was given Dilaudid for pain, Zofran for nausea, given a dose of empiric


IV vancomycin and Zosyn. I do feel the patient will need to be admitted to the hospital. I discussed the patient's case with the hospitalist team for admission. IMPRESSION: 1. Left upper extremity cellulitis with lymphangitis. 2. Rheumatoid arthritis. 3. Heart murmur, possibly new. DISPOSITION: Admission.

II, MD

DD: 18:18:59 DT: 19:13:44

/ cc: MD; ELECTRONICALLY REVIEWED AND SIGNED II (EMER) MD, ON: 14:42 ELECTRONICALLY SIGNED II (EMER) MD, ON: 14:42 Document Name: ED Note-Nursing Document Status: Signed Performed By: Scanned, Documents 16:04 EDT Authenticated By:


Order Date/Time 17:19 EDT Mnemonic sulfamethoxazole-trimethoprim

Action Order

Order Status Completed

Type of Order Pharmacy

Ordering Physician <Unknown>

Order Placed By RN,

Review Information N/A Order Details PO, bid, 0 Order Date/Time 17:01 EDT Mnemonic 48 Hour Return Admit - ED

Action Order

Order Status Discontinued

Type of Order Admit/Transfer/Discharge

Ordering Physician System, Cerner

Order Placed By System, Cerner

Review Information N/A Order Details

17:01:36 EDT

Progress Notes Document Name: Anesthesiology Progress Note Document Status: Signed Performed By: CRNA, 07:41 EDT Authenticated By: CRNA, 07:41 EDT Anesthesia Post Op Note INP Entered On: 7:41 EDT Anesthesia Post Op Note INP Entered On: 7:41 EDT Anesthesia Post Op Note INP Entered On: 7:41 EDT Anesthesia Post Op Note INP Entered On: 7:41 EDT

Performed On: 7:41 EDT by CRNA, Performed On: 7:41 EDT by CRNA, Performed On: 7:41 EDT by CRNA, Performed On: 7:41 EDT by CRNA, Anesthesia Post Op Note INP Anesthesia Post Op Note INP Anesthesia Post Op Note INP Anesthesia Post Op Note INP Respiratory Status Stable including RR & O2Sat : Yes Airway Patency : Yes Hemodynamically Stable including HR & BP : Yes Free of Significant Nausea, Vomitting & Pain : Yes Adequately Hydrated : Yes Mental Status: Returned to Baseline : Yes Temperature Returned to Baseline : Yes

CRNA, - 7:41 EDT Document Name: Pharmacy Progress Note Document Status: Modified Performed By: 11:15 EDT Authenticated By: 11:15 EDT S/O: 58 year old male with sepsis secondary to abscess on hand. Magnetic resonance views reveal tenosynovitis, of infectious vs. inflammatory origin. Patient currently receives Vancomycin 1250mg iv q8h, pharmacist to dose. Vancomycin trough due prior to 10:00 dose today. TBW: 92.6 kg IBW: 84.5 kg Tmax: 36.8 C WBC: 12.1 SCr: 0.82 BUN: 10 A/P: estimated CrCl: > 100; t1/2: 6.8 hr Based on pt wt and renal function, Vancomycin regimen of 1250mg iv q8h appears appropriate to provide


gram positive coverage with target trough range of 15-20 mcg/mL. As above, Vancomycin trough will be obtained at 10:00 today. Pharmacist to evaluate, and adjust regimen as required. From t1/2 of 6.8h, trough should be at steady state. Will continue to follow. Thank you for this consult. Addendum by Rph, on 12:27 EDT 10:00 Vancomycin trough not drawn. Will move Vancomycin trough to 18:00 this evening. This consult appreciated. Addendum by Rph, on 19:14 EDT Pt discharged home on Bactrim, PIV removed. Pharmacy Services will sign off on consult at this time. Thanks,

Document Name: Pharmacy Progress Note Document Status: Modified Performed By: 12:33 EDT Authenticated By: 12:33 EDT S/O: 58 year old male who presented with sepsis secondary to abscess on hand. Overnight, abscess spontaneouly burst, with purulent drainage. Scheduled for further I and D today. Magnetic resonance views reveal tenosynovitis of infectious vs. inflammatory origin. Patient currently receives Vancomycin 1250mg iv q8h, pharmacist to dose. Vancomycin trough due prior to dose tonight. TBW: 88.7 kg IBW: 84.5 kg Tmax: 36.8 C WBC: 12.1 SCr: 0.82 BUN: 10 A/P: estimated CrCl: > 100; t1/2: 6.8 hr Based on pt wt and renal function, Vancomycin regimen of 1250mg iv q8h appears appropriate to provide gram positive coverage with target trough range of 15-20 mcg/mL. As above, Vancomycin trough will be obtained at 22:00 tonight. Pharmacist to evaluate, and adjust regimen as required. From t1/2 of 6.8h, trough should be approaching steady state blood level by this time. Will continue to follow. Thank you for this consult. Addendum by Pharm. D., on 3:34 EDT Vancomycin trough = 15.1mcg/mL, drawn 25min before dose due. This level would, I belive have been higher but still within range of 15-20, had dosing not gotten off during the day. Patient received a dose at 06:00, but then not again until 18:15; it was the 18:15 dose, that the trough represents. Patient's true trough should be within range, without being supratherapeutic. Patient actually appears to be mirroring his initially predicted vancomycin kinetics very closely, exhibiting a half-life ~7hr. As he is very close to ideal body weight, his volume of distribution should be close to the


average of 0.7L/kg. I suspect he will be able to remain on this dose without issue, but will redraw a trough in 36hr to confirm dose. Pharmacy will continue to follow & adjust. Colby Document Name: Pharmacy Progress Note Document Status: Modified Performed By: 10:52 EDT Authenticated By: 10:52 EDT S/O: 58 yo male with cellulitis in left hand, recieving Vanc 2g Q12H. Target Vanc trough 10-15 mcg/mL. TBW: 88.1 kg IBW: 84.5 kg Tmax: 37 C WBC: 12.1 SCr: 0.82 (10/16) BUN: 10 (10/16) Vanc Trough prior to 1300 dose: A/P: Zosyn discontinued. Estimated CrCl: > 100, T1/2: 6.8 hr. Based on pt wt and renal function, Vanc regimen of 2g Q12H appears appropriate to provide gram + coverage with target trough range of 10-15 mcg/mL. As above, Vanc trough will be obtained at 1300. Pharmacist to evaluate and adjust dose based on level if needed. Pharmacy will continue to follow. Thank you for this consult. Addendum by on 15:57 EDT Vanc trough prior to 1300 dose was 12.1 mcg/mL. From T1/2 of 6.8 hr, trough should represent a steady state level. To achieve trough within target range of 15-20 mcg/mL, adjust dose to Vanc 1250 mg IV Q8H. Draw early Vanc trough prior to 2100 dose on 10/19/12. Pharmacy services to evaluate. This consult appreciated. Addendum by on 16:09 EDT Draw early Vanc trough prior to 2200 dose on . Document Name: Pharmacy Progress Note Document Status: Signed Performed By: Rph, 20:37 EDT Authenticated By: Rph, 20:37 EDT Subjective 58 yo male returns to ED after declining request for admission last night with worsening arm cellulitis. Patient has swollen left hand with red streaks from wrist to axilla. Patient was prescribed Keflex and Septra after ED discharge post 1 gm Vanc dose. PMH: Heart murmur, RA recving Remicade/MTX/Prednisone, UC Objective weight= 90.1 kg IBW=84.5 kg ht=75 inches Scr=0.82 BUN=10 estcrcl > 100 ml/min TMax=37.4 WBC=12.2 SIRS= +2


Assessment Sepsis secondary to SSTI Plan -Patient had 1 gm Vanc in ED at 21:30 on -Patient had 1.5 gm Vanc in ED at 19:00 on -Start Vanc 2 gm q12 in 6 hrs, then q12 subsequently and draw trough prior to the 10/18 1300 dose -Continue Zosyn as 3.375 gm q8h In the mean time, pharmacy will monitor patient labs and condition daily. Thank you. Document Name: Progress Note-Physician Document Status: Signed Performed By: (INFE) MD, 12:51 EDT Authenticated By: (INFE) MD, 13:16 EDT

ID Progress note:

A/P:

LUE tenderness has improved, swelling and erythema have improved. Continues to tolerate IV

Vancomcyin, had I+D of left hand . No other changes or complaints in last 24 hours, remains

afebrile, WBC continues to decrease. Operative note reviewed.

Will change today to PO Bactrim DS 1 tab BID next 2 to 3 weeks - script written..

F/U in office 2 weeks.

Problem list:

1. L hand cellulitis w abscess ? CAMRSA. POD #3 I and D

2. Ulcerative colitis.

3. RA - received Remicade 2 weeks ago

Abx:

D/C'd: Zosyn

Vancomycin -

Micro:

Bld Cx x 2/2 ngtd

Left hand GS & Cx MRSA

OR Cx - MRSA

MRI IMPRESSION: Cellulitis with peripheral enhancing lobulated fluid

collections dissecting along the dorsal superficial wrist and hand,

likely cellulitis with abscess formation. Infectious inflammatory

tenosynovitis involving the flexor and extensor compartments. Myositis


in the hypothenar compartment.

Physical Exam

GEN: NAD, awake/alert

Chest: CTAB

CV: RRR, faint murmur 1-2/6 auscultated at RUSB

Abdomen: Soft, nontender, nondistended, NABS

LUE: Left wrist with sutures - all the erythema near wrist, forearm and arm have all resolved. Not

tender on palpation. Bloody drainage at ulnar aspect, but wound is extremely clean.

Skin: no new lesions or rashes

Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 36.8 120/60 63 20 97% Room Air 24 Hr Tmax: 36.8 at 06:28

Intake Output Balance Totals 1962 0 1962 No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED (INFE) MD, ON: 13:16 ELECTRONICALLY SIGNED (INFE) MD, ON: 13:16 Document Name: Progress Note-Physician Document Status: Signed Performed By: MD, 10:57 EDT Authenticated By: MD, 10:57 EDT Subjective No new complaints. pain better. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Ulcerative colitis. 3. GERD. 4. Basal cell carcinoma, status post excision. 5. Cystectomy from his right buttock.


Assessment/Plan Left wrist abscess, cellulitis -continue vancomycin for MRSA -s/p I and D -dressing changes to continue RA - stable UC - stable DVT px - ambulating freely DC home when cleared by ID and ortho - possibly can switch to PO bactrim +/- doxy at discharge Physical Exam NAD Wound was examined after opening the dressing. swelling has decreased but still sig edema and erythema at the proximal and distal most aspect of the wound. proximal site of drain is also open and draining some bloody discharge No leg edema Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 36.8 120/60 63 20 ---- ----------- 24 Hr Tmax: 36.8 at 06:28

Intake Output Balance Totals 1962 0 1962 No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED MD, ON: 10:57 ELECTRONICALLY SIGNED MD, ON: 10:57 Document Name: Progress Note-Physician Document Status: Signed Performed By: MD, 11:35 EDT Authenticated By: MD, 11:35 EDT Subjective Pain not too bad. no fever. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Ulcerative colitis.


3. GERD. 4. Basal cell carcinoma, status post excision. 5. Cystectomy from his right buttock. Assessment/Plan Left wrist abscess, cellulitis -continue vancomycin pending culture data -s/p I and D -dressing changes per ortho RA - stable UC - stable DVT px - ambulating freely Physical Exam NAD Wound neatly dressed. Hand splint noted No leg edema Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 36.7 124/73 66 18 98% Room Air 24 Hr Tmax: 36.7 at 05:43

Intake Output Balance Totals 1320 0 1320 Today's Lab Results

05:45 Procedure Units Ref Range Potassium Lvl 3.9 mmol/L 3.5 - 5.1 ELECTRONICALLY REVIEWED AND SIGNED MD, ON: 11:35 ELECTRONICALLY SIGNED MD, ON: 11:35


Document Name: Progress Note-Physician Document Status: Signed Performed By: PA, 09:48 EDT Authenticated By: (ORTH) MD, 21:17 EDT Orthopaedic Surgery Progress Note On Vancomycin pending culture results. Percocet q6hrs not holding patient for pain control. Dressing dry and intact. No drainage. Per pt's nurse today, dressing changed today, moderate bloody drainage from the proximal wound. no redness or purulent drainage.NVI except decreased sensation left dorsal small and ring fingers proximal phalanx level. Cap refill intact. Minimal swelling of digits. 24 Hr Tmax: 36.7 at 05:43 Most Recent Vitals 05:43 Temp BP Pulse RR SPO2 O2 Therapy 36.7 124/73 66 18 98% Room Air


0545 Potassium Lvl 3.9, Cultures pending, Gram stain c/w staph, few yeast. assessement:s/p left wrist I&D, Dr. Plan: will continue Vancomycin until cultures available tomorrow. Per ID. Continue dressing changes Hand therapy making splint today. Return to work to be determined per Dr. Will d/c Percocet q6 hrs and change to oxycodone 5mg po q4hrs prn pain Continue elevation. ELECTRONICALLY REVIEWED AND SIGNED PA, ON: 09:48 ELECTRONICALLY SIGNED (ORTH) MD, ON: 21:17 Document Name: Progress Note-Physician Document Status: Signed Performed By: MD, 12:59 EDT Authenticated By: MD, 12:59 EDT Subjective He fe els better since I and D. no fever. pain not too bad. PAST MEDICAL HISTORY: 1. Rheumatoid arthritis.


2. Ulcerative colitis. 3. GERD. 4. Basal cell carcinoma, status post excision. 5. Cystectomy from his right buttock. Assessment/Plan Left wrist abscess, cellulitis -continue vancomycin pending culture data -s/p I and D -dressing removed. drain removed RA - stable UC - stable DVT px - ambulating freely Physical Exam NAD I helped RN remove dressing and drain Wound was still quite swollen with bloody ooze from drain site but no pus draining No leg edema Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 36.9 102/64 68 18 96% Room Air 24 Hr Tmax: 36.9 at 05:53


01:35 Procedure Units Ref Range Vanco Tr 15.1 ug/mL 10.0 - 20.0 ELECTRONICALLY REVIEWED AND SIGNED MD, ON: 12:59 ELECTRONICALLY SIGNED MD, ON: 12:59


Document Name: Progress Note-Physician Document Status: Signed Performed By: (INFE) MD, 09:27 EDT Authenticated By: (INFE) MD, 09:27 EDT ID Input: OR cx and floor cx with GPCs Should continue Vancomycin. will reassess Monday. ELECTRONICALLY REVIEWED AND SIGNED (INFE) MD, ON: 09:27 ELECTRONICALLY SIGNED (INFE) MD, ON: 09:27 Document Name: Progress Note-Physician Document Status: Signed Performed By: PA, 07:37 EDT Authenticated By: (ORTH) MD, 12:27 EDT Orthopaedic Surgery Progress Note POD 1 S: no complaints A: hand elevated. nvi. dressing clean P: IV antibx, per Dr. 24 Hr Tmax: 36.9 at 05:53 Most Recent Vitals 05:53 Temp BP Pulse RR SPO2 O2 Therapy 36.9 102/64 66 18 ---- -----------


0135 Vanco Tr 15.1, ELECTRONICALLY REVIEWED AND SIGNED PA, ON: 07:37 ELECTRONICALLY SIGNED (ORTH) MD, ON: 12:27


Document Name: Progress Note-Physician Document Status: Signed Performed By: (INFE) NP, 11:46 EDT Authenticated By: (INFE) MD, 15:17 EDT

ID Progress note:

A/P:

Left ulnar abscess spontaneously burst last night and released purulent discharge. GS+Cx obtained and

sent to micro lab accordingly, growing GPC, awaiting susceptibilities. If MRSA positive will initiate

isolation precautions and select subsequent abx course accordingly. Bld cx x2/2 ) remain negative,

will continue to monitor.

LUE tenderness has dissipated, swelling and erythema have improved. Continues to tolerate IV

Vancomcyin, awaiting I+D of left hand today. No other somatic changes or complaints in last 24 hours,

remains afebrile, WBC continues to decrease. Will f/u on cx and await intra-operative findings.

Problem list:

1. L hand cellulitis w abscess, GPC +, ? CAMRSA.



Abx:

D/C'd: Zosyn

Vancomycin -

Micro:

Bld Cx x 2/2 ) ngtd

Left hand GS & Cx ( ) GPC

MRI IMPRESSION: Cellulitis with peripheral enhancing lobulated fluid

collections dissecting along the dorsal superficial wrist and hand,

likely cellulitis with abscess formation. Infectious inflammatory

tenosynovitis involving the flexor and extensor compartments. Myositis

in the hypothenar compartment.

Physical Exam

GEN: NAD, awake/alert

Chest: CTAB



LUE: radial/ulnar swelling; erythemic, taut and tender at left ulnar aspect with obvious thick

opaque/purulent drainage, no peripheral fluctuance/induration, cpr < 2 secs, no cyanosis, no palpable left


olecranol nodes. Patient continues to exhibit restricted left hand ROM, however it is improved compared

to .

SKIn: no new lesions or rashes

Objective

Vitals

Temp BP Pulse RR SPO2 O2 Therapy

36.8 114/63 72 20 ---- -----------

24 Hr Tmax: 36.8 at 06:23

Intake Output Balance

Totals 2111 0 2111

No 24 Hour Lab Data

ID staff Note:

Patient is currently in OR. Will await cx data. Continue Vancomycin from now. ELECTRONICALLY REVIEWED AND SIGNED (INFE) NP, ON: 11:48 ELECTRONICALLY SIGNED (INFE) MD, ON: 15:17 Document Name: Progress Note-Physician Document Status: Signed Performed By: MD, 10:28 EDT Authenticated By: MD, 12:57 EDT Subjective The abscess ruptured last night and drained lots of pus. He states, "if I was given a choice to be operated on last night, I would have opted for it". PAST MEDICAL HISTORY: 1. Rheumatoid arthritis. 2. Ulcerative colitis. 3. GERD. 4. Basal cell carcinoma, status post excision. 5. Cystectomy from his right buttock. Assessment/Plan


Left wrist abscess, cellulitis -continue vancomycin -for I and D today RA - stable UC - stable DVT px - ambulating freely Physical Exam Chest: Clear CV: RRR Abdomen: Soft, nontender, nondistended, NABS Extremities: left wrist wound dressing is soaked with pus - wound was examined - severe inflammation noted with 2 areas of rupture noted, oozing thick cheesy pus Neck: No JVD Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 36.8 114/63 72 20 ---- ----------- 24 Hr Tmax: 36.8 at 06:23

Intake Output Balance Totals 2111 0 2111 No 24 Hour Lab Data Document Name: Progress Note-Physician Document Status: Modified Performed By: (INFE) NP, 11:35 EDT Authenticated By: (INFE) MD, 17:16 EDT

ID Progress note:

Patient continues to report tenderness in LUE, however the swelling has improved though not resolved.

Tolerating IV Vancomcyin, awaiting repeat MRI with contrast today and awaiting ortho surgery consult

regarding need for I+D. Bld cx x2/2 remain negative, will continue to monitor. Continue IV Vancomycin at

this time - trough is 12.3 today.

Problem list:

1. L hand cellulitis w likely abscess.




Abx:

D/C'd: Zosyn

Vancomycin

Micro:

Bld Cx x 2/2 ngtd

Radiology:

MRI left hand with contrast - Cellulitis with peripheral enhancing lobulated fluid collections dissecting along the dorsal superficial wrist and hand, likely cellulitis with abscess formation. Infectious inflammatory tenosynovitis involving the flexor and extensor compartments. Myositis in the hypothenar compartment.

Physical Exam

GEN: NAD

Chest: CTAB



LUE: radial/ulnar swelling ascending to olecranonal aspect, erythema - has progressed beyond marked area on dorsal wrist area (RP), taut, tender, restricted ROM, cpr < 2 secs, no cyanosis, palpable olecranol

or left axillary nodes.Scab observed on lateral ulnar aspect, without fluctuance/induration.

SKIn: no new lesions or rashes

Objective

Vitals

Temp BP Pulse RR SPO2 O2 Therapy

36.9 118/62 76 18 100% Room Air

24 Hr Tmax: 37.0 at 21:32

Intake Output Balance

Totals 950 0 950

No 24 Hour Lab Data I D staff Note Patient seen and examined. Discussed with Ms. Findings confirmed - MRI post contrast demonstrating abscess - he needs a surgical I and D performed.Awaits surgical consult - I will contact Dr. and follow up on surgical consult. I will make patient NPO in case he goes to OR


tonight. ELECTRONICALLY REVIEWED AND SIGNED (INFE) NP, ELECTRONICALLY SIGNED (INFE) MD, ON: 17:16 Addendum by (INFE) MD, on 17:28 EDT Ortho surgeon here to see patient - will take to OR . NPO after midnight. ELECTRONICALLY REVIEWED AND SIGNED (INFE) MD, ON: 17:28 Document Name: Progress Note-Physician Document Status: Signed Performed By: (INTE) MD, 10:03 EDT Authenticated By: (INTE) MD, 10:03 EDT Subjective L wrist swelling and pain seem to be better . Percocet x 2 in last 24 hrs. Assessment/Plan 1. L hand cellulitis w likely abscess. No evidence for osteomyelitis on MRI. For some reason, contrasted imaging not done. -Will try to obtain contrasted images today. -Continue Vanc (started ). - Ortho consult to eval for I and D. -Appreciate ID's assistance. 2. Ulcerative colitis. -Hold prednisone for now given cellulitis. 3. Dispo. Home pending above. Physical Exam General: Laying comfortably in bed, NAD. Neck : No JVD. Chest: CTAB w/o wheezes or crackles. CV: RRR w I/VI sys murmur. Radial pulses 2+ bilaterally. Abdomen: Bowel sounds present, s oft, nontender, nondistended. Extremities: No edema . L wrist still swollen, looks like some dried serosang drainage from scab, erythema w no significant change, less streaking than yesterday. Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 36.9 118/62 76 18 100% Room Air 24 Hr Tmax: 37.0 at 21:32


Intake Output Balance Totals 950 0 950 No 24 Hour Lab Data ELECTRONICALLY REVIEWED AND SIGNED ., (INTE) MD, ON: 10:03 ELECTRONICALLY SIGNED (INTE) MD, ON: 10:03 Document Name: Progress Note-Physician Document Status: Signed Performed By: , (INTE) MD, 10:32 EDT Authenticated By: , (INTE) MD, 10:32 EDT Subjective Wants to go home. Redness in arm is better. Assessment/Plan 1. L hand cellulitis, improving -Continue Vanc, Zosyn for now (started ). I think he does need MRSA coverage. When he does go home, maybe Augmentin and Bactrim? Will see what ID thinks. 2. Heart murmur. Doesn't seem that impressive to me today. No systemic symptoms to make me think of endocarditis. -F/U TTE. 3. Ulcerative colitis. -Hold prednisone for now given cellulitis. 4. Dispo. Home pending above, hopefully in next day or so. Physical Exam General: Laying comfortably in bed, NAD. Neck : No JVD. Chest: CTAB w/o wheezes or crackles. CV: RRR w/o murmurs. Radial pulses 2+ bilaterally. Abdomen: Bowel sounds present, s oft, nontender, nondistended. Extremities: No edema . Skin: Small scab on dorsal L hand w surrounding erythema and induration but no fluctuance. Lymphangitic streaking up L arm seems to have improved significantly. Objective Vitals Temp BP Pulse RR SPO2 O2 Therapy 37.5 104/57 82 18 96% Room Air 24 Hr Tmax: 37.5 at 06:14



04:50 Procedure Units Ref Range Potassium Lvl 4.0 mmol/L 3.5 - 5.1 WBC 12.1 H k/uL 3.5 - 10.5 RBC 4.09 L M/uL 4.32 - 5.72 Hgb 13.5 g/dL 13.5 - 17.5 Hct 37.8 L % 38.0 - 50.0 MCV 92.5 fL 81.0 - 95.0 RDW 13.2 % 12.0 - 15.0 Platelet 149 L k/uL 150 - 450 Neutro 76 % 42 - 78 Lymph 15 L % 16 - 52 Mono 8 % 1 - 11 Eos 1 % 0 - 7 Basophil 0 % 0 - 4 Neutro Abs 9.20 H k/uL 2.10 - 6.30 ELECTRONICALLY REVIEWED AND SIGNED , (INTE) MD, ON: 10:32 ELECTRONICALLY SIGNED Jr., (INTE) MD, ON: 10:32 Document Name: Progress Note-Nurse Document Status: Signed Performed By: RN, 11:43 EDT Authenticated By: RN, 11:43 EDT Provider Notification/Callback Entered On: 11:45 EDT Provider Notification/Callback Entered On: 11:45 EDT Provider Notification/Callback Entered On: 11:45 EDT Provider Notification/Callback Entered On: 11:45 EDT

Performed On: 11:43 EDT by RN, Performed On: 11:43 EDT by RN, Performed On: 11:43 EDT by RN, Performed On: 11:43 EDT by RN, Provider Notification Provider Notification Provider Notification Provider Notification Notification Call Reason : Other: lab results

RN, - 11:43 EDT Provider Notification Grid Notified Date/Time :

11:40 EDT

Read-Back : Yes Follow-Up : No Follow Up Interventions :

No Order Changes

RN, -

11:43 EDT


Hematology General Hematology Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes Procedure

Units Ref Range

WBC k/uL

[3.5-10.5]

RBC M/uL

[4.32-5.72]

Hgb g/dL

[13.5-17.5]

Hct %

[38.0-50.0]

Platelet k/uL

[150-450]

RDW %

[12.0-15.0]

MCV fL

[81.0-95.0] 04:50 EDT 12.1 H 4.09 L 13.5 37.8 L 149 L 13.2 92.5 18:02 EDT 12.2 H 4.32 14.2 39.7 148 L 13.1 91.9

Differential Legend: A=Abnormal, C=Critical, *=Interpretive Data @=Corrected, L=Low, H=High, f=footnotes Procedure

Units Ref Range

Neutro %

[42-78]

Lymph %

[16-52]

Mono %

[1-11]

Eos %

[0-7]

Basophil %

[0-4]

Neutro Abs k/uL

[2.10-6.30] 04:50 EDT 76 15 L 8 1 0 9.20 H 18:02 EDT 83 H 8 L 7 1 0 10.13 H

Chemistry General Chemistry Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes Procedure

Units Ref Range

Sodium Lvl mmol/L

[134-145]

Potassium Lvl mmol/L [3.5-5.1]

Chloride mmol/L [98-107]

CO2 mmol/L

[21.0-32.0]

BUN mg/dL [7-18]

Creatinine * mg/dL

[0.80-1.30] 05:45 EDT 3.9 04:50 EDT 4.0 18:02 EDT 137 3.7 104 25.0 10 0.82

18:02 EDT Creatinine:

* This creatinine method is traceable to a GC-IDMS method and NIST standard reference material. Procedure

Units Ref Range

eGFR - African

eGFR - Non-African *

Glucose Lvl mg/dL [65-99]

Calcium Lvl mg/dL

[8.5-10.1] 18:02 EDT >60 f >60 f 94 8.3 L

18:02 EDT eGFR - Non-African:

The eGFR is calculated using the four parameter MDRD equation for IDMS-traceable creatinine. eGFR < 60 indicates chronic kidney disease, eGFR < 15 indicates kidney failure.

2 18:02 EDT eGFR - African: eGFR calculated by Discern Logic.

18:02 EDT eGFR - Non-African: eGFR calculated by Discern Logic.


Drugs/Toxicology

Legend: A=Abnormal, C=Critical, *=Interpretive Data, @=Corrected, L=Low, H=High, f=footnotes

Procedure Units

Ref Range

Vanco Tr * ug/mL

[10.0-20.0] 01:35 EDT 15.1 12:23 EDT 12.1

12:23 EDT

* For complicated infections the recommended vancomycin trough target is 15-20 ug/mL. Refer to pharmacy recommendation.

Microbiology - Blood Cultures PROCEDURE: Blood Culture SOURCE: Venous COLLECTED: 18:02 EDT STARTED: 18:27 EDT ACCESSION: *** FINAL REPORT *** Final Report Verified 22:00 EDT No growth. __________________________________________________________ PROCEDURE: Blood Culture SOURCE: Venous COLLECTED: 18:02 EDT STARTED: 18:27 EDT ACCESSION: *** FINAL REPORT *** Final Report Verified 22:00 EDT No growth. __________________________________________________________


Microbiology - Other Cultures PROCEDURE: Aerobic Culture and GS SOURCE: Abscess COLLECTED: 13:49 EDT BODY SITE: Left Hand STARTED: 14:25 EDT ACCESSION: *** STAINS / PREPARATIONS *** Gram Stain Amended Verified 06:12 EDT Moderate Gram Positive Cocci Many white blood cells Please disregard previous gram stain report FewYeast, Moderate White Blood Cells. Gram Stain Report Verified 15:39 EDT Few Yeast Moderate white blood cells *** FINAL REPORT *** Final Report Verified: 10:33 EDT Staphylococcus aureus For susceptibility results refer to accession # *** ORDER COMMENTS *** Collection Instructions: Culturette swab. __________________________________________________________ PROCEDURE: Aerobic Culture and GS SOURCE: Abscess COLLECTED: 20:50 EDT BODY SITE: Left Hand STARTED: 00:33 EDT ACCESSION: *** STAINS / PREPARATIONS *** Gram Stain Report Verified:1 10:04 EDT Few Gram Positive Cocci Many white blood cells *** FINAL REPORT *** Final Report Verified: 11:28 EDT Methicillin-Resistant Staphylococcus aureus


*** SUSCEPTIBILITY RESULTS *** Methicillin-Resistant Staphylococcus aureus ___________________________________________ MIC(ug/mL) MIC Interp ____________ ____________ Ciprofloxacin(1) <=0.5 S Clindamycin(2) <=0.25 S Erythromycin >=8 R Levofloxacin 0.25 S Oxacillin(3) >=4 R Trimethoprim/Sulfa <=10 S Tetracycline <=1 S Vancomycin 1 S S=Susceptible, I=Intermediate, R=Resistant, N/A=Not Applicable *** ORDER COMMENTS *** Collection Instructions: Culturette swab.

11:32 notified RN of MRSA. KD *** FOOTNOTES *** (1) Levofloxacin is the preferred fluoroquinolone at Rex Healthcare. (2) Isolate does not demonstrate inducible Clindamycin resistance in-vitro. (3) Methicillin Resistant Staph. aureus (MRSA) isolated: please check Infection Control Policy. Oxacillin resistant staphylococci are resistant to cefazolin and all other beta-lactams. __________________________________________________________

Microbiology - Anaerobic Cultures PROCEDURE: Anaerobic Culture SOURCE: Abscess COLLECTED: 13:49 EDT BODY SITE: Left Hand STARTED: 14:25 EDT ACCESSION: *** FINAL REPORT *** Final Report Verified: 11:05 EDT No Anaerobes isolated.


** * ORDER COMMENTS *** Collection Instructions: Swabs in a Port-a-Cul tube. Tissue in a sterile cup. Body Fluid in a sterile cup or capped syringe. __________________________________________________________

Microbiology - Fungal Cultures PROCEDURE: Fungal Culture SOURCE: Abscess COLLECTED: 13:49 EDT BODY SITE: Left Hand STARTED: 14:25 EDT ACCESSION: *** FINAL REPORT *** Final Report Verified: 12:31 EST No fungi isolated. __________________________________________________________

Microbiology - AFB Cultures PROCEDURE: Acid Fast Bacilli Culture and Smear SOURCE: Abscess COLLECTED: 13:49 EDT BODY SITE: Left Hand STARTED: 11:00 EDT ACCESSION: *** STAINS / PREPARATIONS *** Acid Fast Stain Report Verified: 14:32 EDT No Acid Fast Bacilli seen. Specimens collected on swabs are suboptimal for the isolation of mycobacteria. *** PRELIMINARY REPORT *** Preliminary Report Verified: 08:53 EDT No AFB isolated to date-Lab will update if status changes. __________________________________________________________


Magnetic Resonance Imaging Accession Number Exam Exam Date/Time Ordering Physician

MR Arm Joint W/ Contrast Left

12:15 EDT , (INTE) MD,

CPT4 Codes 73222 (MR Arm Joint W/ Contrast Left) CDM Codes 36231 (MR Arm Joint W/ Contrast Left), 53804 (INJ GADOLINIUM MRI CONTRAST/ML) Reason For Exam L dorsal wrist swelling, concern for abscess. Need contrasted images to assess for abscess;Other-Please complete Reason For Exam free text Report HISTORY: Cellulitis and tenosynovitis, assess for abscess TECHNIQUE: Multiplanar T1 fat-saturated images acquired following uneventful injection of 18 cc Magnevist. FINDINGS: Comparison noncontrast MRI performed one day earlier. Lobulated peripheral enhancing fluid collection of the ulnar aspect of the distal forearm dissects along the subcutaneous fat. The largest irregular pocket of fluid measures 32 x 8 x 23 mm, with thin tubular communication channels into a similar sized 33 x 10 x 15 mm collection fluid that dissects distally along the dorsal ulnar wrist to the level of the fourth metacarpal head. Mild perimuscular and intramuscular enhancement in the hypothenar compartment on axial images 40-46, without intramuscular abscess. Nonspecific enhancement about the extensor and flexor tendon groups confirms tenosynovitis. Subchondral enhancement along the distal radius at the radiolunate articulation, may represent sequelae of erosive arthritis given history rheumatoid disease. IMPRESSION: Cellulitis with peripheral enhancing lobulated fluid collections dissecting along the dorsal superficial wrist and hand, likely cellulitis with abscess formation. Infectious inflammatory tenosynovitis involving the flexor and extensor compartments. Myositis in the hypothenar compartment. ***** Final ***** Signed (Electronic Signature): 12:23 pm Signed by: (RAD) MD, Transcribed by:


Accession Number Exam Exam Date/Time Ordering Physician MR Arm Non-Joint W/O

Contrast Left MD,

CPT4 Codes 73218 (MR Arm Non-Joint W/O Contrast Left) CDM Codes 36226 (MR Arm Non-Joint W/O Contrast Left) Reason For Exam Infection Report HISTORY: Fever, hand pain, assess for cellulitis. TECHNIQUE: Standard noncontrast MRI of the left arm. The exam is truncated secondary to patient difficulty with further scanning. FINDINGS: Diffuse soft tissue edema across the dorsal and ulnar aspect of the wrist and forearm. Lobulated appearing fluid accumulation across the ulnar aspect of the distal forearm is seen on axial images 25-30, may represent small fluid collections measuring 10 x 25 mm. Fluid present within the extensor tendon sheaths compatible with tenosynovitis. No focal tendon disruption. The flexor tendons show minimal fluid accumulation to the carpal tunnel. Edema like signal change in the flexor carpi ulnaris. No intramuscular fluid collection. Bony structures demonstrate subchondral cystic change and periarticular erosions in the proximal carpal row, likely from known history of rheumatoid arthritis. No cortical erosion or edema like signal change to indicate developing osteomyelitis. IMPRESSION: 1. Reactive inflammatory changes in the left forearm. Findings most suggestive of cellulitis/myositis, potentially with developing fluid collection in the superficial aspect of the ulnar forearm, abscess not excluded. If The patient can tolerate additional scanning, postcontrast imaging is recommended. 2. Arthropathic changes compatible with rheumatoid arthritis. Tenosynovitis changes are nonspecific, can be seen in setting of rheumatoid arthritis or infectious tenosynovitis. ***** Final ***** Signed (Electronic Signature): 6:53 am Signed by: (RAD) MD, Transcribed by:


Echocardiogram Procedures Accession Number Exam Exam Date/Time Ordering Physician

HT Cardiac Echo (INTE) MD, Report

Transthoracic

Echo Report Exam Date: 09:11 Ordering Physician: (INTE), Age: 58 Gender: M Exam Location: Referring Physician: .INHOUSE, DOB: Ht (in): 75 Wt (lb): 200 CC: MRN: EHR CC: Reading Physician: MD Sonographer: RDCS Procedure CPT: 93306 Indications: Endocarditis ICD-9 Codes: Pt. History: Ulcerative colitis, remicade, cellulitis BP: 104 / 57 HR: Rhythm: Technical Quality: IMPRESSIONS Normal left ventricular size with mildly increased wall thickness. Normal systolic function with no obvious regional wall motion abnormalities. The estimated ejection fraction is 60-65%. Chordal SAM and mild LVOT gradient present of <20 mm HG. Septal E/E' ratio is 13.5 indicating normal filling pressure. The right ventricle is normal in size and function. The right atrium is normal in size. The left atrium is normal in size. Structurally normal mitral valve. Mild mitral regurgitation. No vegetations seen (suggest transesophageal echo if suspicion high). Aortic valve appears to be sclerotic without evidence of stenosis. No vegetations seen (suggest transesophageal echo if suspicion high. Normal appearance and motion of the tricuspid valve. Trace tricuspid regurgitation. No vegetations seen (suggest transesophageal echo if suspicion high). Pulmonic valve not well visualized. Mild pulmonic regurgitation. No vegetations seen (suggest transesophageal echo if suspicion high. Normal pericardium without effusion. IVC appears normal. Mild aortic dilatation at the level of the sinuses of valsalva (root). FINDINGS Left Ventricle Normal left ventricular size with mildly increased wall thickness. Normal systolic function with no obvious regional wall motion abnormalities. The estimated ejection fraction is 60-65%. Chordal SAM and mild LVOT gradient present of <20 mm HG. Septal E/E' ratio is 13.5 indicating normal filling pressure. Right Ventricle The right ventricle is normal in size and function. Right Atrium The right atrium is normal in size. Left Atrium The left atrium is normal in size. Mitral Valve Structurally normal mitral valve. Mild mitral regurgitation. No vegetations seen (suggest transesophageal echo if suspicion high).


Aortic Valve Aortic valve appears to be sclerotic without evidence of stenosis. No vegetations seen (suggest transesophageal echo if suspicion high. Tricuspid Valve Normal appearance and motion of the tricuspid valve. Trace tricuspid regurgitation. No vegetations seen (suggest transesophageal echo if suspicion high). Pulmonic Valve Pulmonic valve not well visualized. Mild pulmonic regurgitation. No vegetations seen (suggest transesophageal echo if suspicion high. Pericardium Normal pericardium without effusion. Vessels IVC appears normal. Mild aortic dilatation at the level of the sinuses of valsalva (root). MEASUREMENTS (Male / Female) Normal Values 2D ECHO LV Diastolic Diameter PLA 5.1 cm 4.2 - 5.9 / 3 LV Relative Wall Thicknes 0.5 LV Systolic Diameter PLAX 3.2 cm Aortic Root Diameter 3.7 cm IVS Diastolic Thickness 1.2 cm 0.6 - 1.0 / 0 LA Systolic Diameter LX 3.1 cm 3.0 - 4.0 / 2.7 - 3. 8 cm LVPW Diastolic Thickness 1.2 cm 0.6 - 1.0 / 0.6 - 0.9 cm DOPPLER AV Peak Velocity 219.8 cm/s LVOT Velocity Time Integr 44.5 cm AV Peak Gradient 19.3 mmHg Mitral E Point Velocity 108.4 cm/s AV Mean Gradient 13.4 mmHg Mitral A Point Velocity 59.1 cm/s AV Velocity Time Integral 49.0 cm Mitral E to A Ratio 1.8 LVOT Peak Velocity 176.8 cm/s MV Deceleration Time 256.7 ms LVOT Peak Gradient 12.5 mmHg MD (Electronically Signed) Final Date: 13:22 ***** Final ***** (CARD) MD, Signed (Electronic Signature): 1:23 pm Signed by: (CARD) MD, Transcribed by: