34 Year Old Man

Patient Note:

Real Case

False Date of Birth

Demographics / Background

• AO x4, independent

• Hx of leaving AMA for drug use (“fix”)

• PMH: substance use (cocaine, opioids), IVDU

Hospital Course

• 9/2: Presented with left forearm swelling/redness → admitted for cellulitis, underwent I&D → left AMA prior to full work-up.

• 9/17: Returned with worsening left forearm cellulitis and new left foot wound → admitted to Plastic Surgery for cellulitis treatment.

  • Underwent I&D of left wrist and left foot.

  • Pathology pending.

• Now: Transferred to Medicine for further work-up and management.

Current Status

• Blood cultures: MRSA positive

• TTE (9/19): no vegetations

• OR wound cultures: polymicrobial (staph, strep, anaerobes)

• MRI L foot: no osteomyelitis

• On IV vancomycin + zosyn for anticipated 4-week course (per ID)

• Patient has expressed desire to leave hospital → contingency PO antibiotics plan from ID in place.

Exam

• General: Well-appearing, NAD

• Vitals: Stable

• CV: RRR, no m/r/g

• Lungs: CTAB

• Abdomen: Soft, NTND

• Extremities: L forearm + L foot wounds wrapped, clean/dry bandages

Active Problems

1. Left forearm cellulitis

2. Left foot cellulitis

3. MRSA bacteremia

4. Opioid use disorder

5. Acute pain

Plan

• Antibiotics: Continue IV vancomycin + zosyn (per ID). If patient leaves AMA, PO antibiotics per ID contingency.

• Infectious work-up:

  • F/u syphilis, HIV, HCV

  • Offer Hep A and Hep B vaccination at discharge

• Pain control (APS consulted):

  • Scheduled: methocarbamol q8h, acetaminophen 975mg q6h, ibuprofen 600mg q6h, gabapentin 300mg TID

  • PRN: dilaudid 1mg q3h, morphine 30mg q4h or 45mg q3h

• Follow-up: Pathology results

• Diet: Regular

• PPx: Lovenox

• Lines: 1 PIV

• Foley: None

• Code status: Full