tokens: Admission Date : 2020-03-11 Discharge Date : 2020-03-23 Date of Birth : 1946-04-03 Sex : M Service : MEDICINE Allergies : Penicillins Attending : Ross Z Kenmore , M.D. Chief Complaint : Transfer from Newton-Wellesley Hospital hospital for epidural abscess Major Surgical or Invasive Procedure : 1. Partial vertebrectomy of L3 and L4 . 2. Fusion at L3-L4 . 3. Vertebral Spacer at L3-L4 . 4. Anterior instrumentation L3-L4 . 5. Autograft , bone morphogenic protein , and allograft . 6. Debridement 7. Incision and drainage 8. Echocardiogram History of Present Illness : 73 yo M transferred from Newton-Wellesley Hospital hospital for epidural abscess . Pt has h/o colon can to liver , s/p resxn with serosal implants in 9/03 . Pt states he has been receiving chemotherapy up until 1 week ago . States he first developed back pain 5 weeks ago but was still able to ambulate with his cane . Last week it was worse and he was seen in clinic . An MRI was done and this showed a signal abno in L3 L4 ? disciitis vs osteo without a definitive epidural abscess . Initially on Vanc and Cipro on Friday but then seen by ID who reccommended no abx but a bone biopsy , blood cx . He was also seen by spine who repeated the MRI and this showed L3-4 osteomyelitis and discitis and an epidural abscess , 5cm . He was subsequently restared on Vancomycin for Corynebacterium in blood cx from Fri ; Followup cx has been NGTD . CXR also showed small pleural effusion and attempt was made to tap it , but pt did not tolerate the procedure and asked that it be deferred . He did undergo a CT-guided aspiration / biopsy at the L3-4 disc space on 2020-03-11 and the pt was transferred to Mediplex Rehab Hospital immediately following this . No results from this were sent . Currently pt denies sensory deficits or weakness . States he is not able to walk because of severe pain . States pain is worst when he sits up or twists his back . No bowel or bladder incontinence . Past Medical History : - epidural abscess - colon cancer with mets to liver s/p resection 09-07 . Oncologist is Dr. Rowles . - CAD s/p CABG x4 in ' 03 . - hypercholesterolemia - DM with neuropathy . - persistent R foot ulcer Social History : Lives alone in apartment in Boston . Is married but " separated " from his wife , although they still help each other - he states he gives her one of his pensions and she helps him with medicines etc . Quit tobacco in 2003 after smoking 1 ppd for " a very long time ". Drank ETOH heavily until 8 years ago when he quit . Denies IVDU . Has children but they are not nearby . Family History : NC Physical Exam : 98.6 , 104/50 , 96 , 20 , 96% RA Gen : in NAD , but winces in pain with movements of his back . HEENT : Clear OP , MM very dry . NECK : Supple , No LAD , No JVD CHEST : Port a cath in R chest , no erythema or tenderness . CV : RR , NL rate . NL S1 , S2 . II/VI SEM at LSB with radiation to apex . LUNGS : + crackles at L base > R base . ABD : Pt very tense in abdomen ( states belly is fine , but he is weary of his back ). Well healed midline scar from chest down to pubis . No HSM . EXT : No edema . Dressing c/d/i over R LE ulcer . 1 + DP pulses BL NEURO : A&Ox3 . Appropriate . CN 02-17 grossly intact . Preserved sensation throughout . 5/5 strength throughout , though weary of moving back . Back : + ttp of lumbar spine and paraspinal muscles , R > L . No erythema or swelling noted . CMED CSRU : Listens and responds to questions appropriately , pleasant Pertinent Results : Na : 135 , K 4.5 , Cl 96 , CO2 27 , BUN 12 , Cr 0.7 , Glu 167 , Ca 8.4 , Vanco trough 13 , WBC 5.3 , Hct 32.0 , plt 330 , INR 1.0 . No culture data was sent . STUDIES : MRI lumbar spine ( Youville Hospital 2020-03-10 ): L3-4 osteomyelitis , discitis , and epidural abscess . Degenerative changes including multilevel central spinal stenosis . Impression on the anterior aspect of the lower spinal cord at T11-12 by disc bulge . Addendum : Findings are c/w paraspinous extension of infection anteriorly and laterally into the medial aspects of the psoas muscles bilaterally at the L3 and L4 levels . CXR ( Youville Hospital 2020-03-09 ): Persistent unchanged L mid and lower lung field airspace disease with moderate L pleural effusion . Brief Hospital Course : 73 yo M transferred from Youville Hospital with h/o colon cancer with known liver mets now with epidural abscess and corynebacterium bacteremia : # Epidural abscess : The patient was evaluated by orthopedic spine consult service and ID . He was continued on IV vancomycin throughout his course and had therapeutic troughs . The patient was taken to the OR twice with orthopaedics . Please see the operation notes for details about the surgeries . The patient was briefly admitted to the ICU for low hematocrit and hyponatremia immediately following the surgery but was then transferred back to the floor in stable condition . The patient had a PICC line placed and will continue a 8 week course of antibiotics . The patient will also wear a back brace at all times while out of bed . # Candidemia : The patient was noted to have a positive blood culture from 03-12 . The patient was started on Diflucan . Ophthalmology was consulted and ruled out ocular spread . The patient 's portocath was removed . The tip was culture negative . The patient will get a total of a two week course of Diflucan . # Corynebacterium bacteremia : presumably Corynebacterium in epidural abscess as well . The patient had no blood cultures to grow corynebacterium while hospitalized . # Pleural effusion : The patient was noted have an effusion on CXR . IP was consulted and did a thoracentesis . The tap was negative for malignant cells . A repeat CT was done showing nodular thickening along the right major and minor fissure , concerning for intrapleural tumor implants . IP reviewed the films and recommended continue oncologic care according to outpatient course and pleurodesis if the pt becomes symptomatic 02-07 fluid accumulation . The patient will follow up with his oncologist . # Foot ulcer : diabetic ulcer s/p surgery but never healed . Wound care was consulted and made recommendations for ulcer care . His dressings were changed by the nursing staff accordingly . # Anemia : His HCT remained stable post-surgery . The patient was continued on his iron supplements . Medications on Admission : - Iron Sulfate 300 mg po tid - Procrit 40,000 units SC q Friday - Lovenox 40 mg SC q24 for DVT ppx - Albuterol / Atrovent nebs q4 - Morphine 2-4 mg IV q3-4 prn - Mylanta 30 cc po q6 prn - Pepcid 20 mg po daily - insulin sliding scale - glipizide 5 mg po bid - metformin 500 mg po bid - metoprolol 50 mg po daily - Vancomycin 1.5 gm q 12 hours Discharge Medications : 1. Albuterol Sulfate 0.083 % Solution Sig : One ( 1 ) Inhalation Q4H ( every 4 hours ) as needed . 2. Ipratropium Bromide 0.02 % Solution Sig : One ( 1 ) Inhalation Q6H ( every 6 hours ) as needed . 3. Aluminum-Magnesium Hydroxide 225-200 mg / 5 mL Suspension Sig : 15-30 MLs PO QID ( 4 times a day ) as needed . 4. Glipizide 5 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ). 5. Miconazole Nitrate 2 % Powder Sig : One ( 1 ) Appl Topical TID ( 3 times a day ) as needed . 6. Acetaminophen 325 mg Tablet Sig : Two ( 2 ) Tablet PO Q6H ( every 6 hours ) as needed for fever or pain . 7. Metoprolol Tartrate 25 mg Tablet Sig : 1.5 Tablets PO BID ( 2 times a day ). 8. Cepacol 2 mg Lozenge Sig : One ( 1 ) Lozenge Mucous membrane PRN ( as needed ). 9. Docusate Sodium 100 mg Capsule Sig : One ( 1 ) Capsule PO BID ( 2 times a day ). 10. Senna 8.6 mg Tablet Sig : One ( 1 ) Tablet PO BID ( 2 times a day ) as needed . 11. Oxycodone 5 mg Tablet Sig : 1-2 Tablets PO every 4-6 hours as needed for pain for 14 days . 12. Fluconazole 200 mg Tablet Sig : Two ( 2 ) Tablet PO Q24H ( every 24 hours ) for 7 days . 13. Oxycodone 10 mg Tablet Sustained Release 12 HR Sig : One ( 1 ) Tablet Sustained Release 12HR PO Q12H ( every 12 hours ). 14. Bisacodyl 5 mg Tablet , Delayed Release ( E.C. ) Sig : Two ( 2 ) Tablet , Delayed Release ( E.C. ) PO BID ( 2 times a day ) as needed . 15. Aspirin 81 mg Tablet , Chewable Sig : One ( 1 ) Tablet , Chewable PO DAILY ( Daily ). 16. Vancomycin in Dextrose 1 g / 200 mL Piggyback Sig : One ( 1 ) Intravenous Q 12H ( Every 12 Hours ): To finish on 2020-05-12 . 17. Pepcid 20 mg Tablet Sig : One ( 1 ) Tablet PO once a day . 18. Heparin Lock Flush ( Porcine ) 100 unit / mL Syringe Sig : Two ( 2 ) ML Intravenous DAILY ( Daily ) as needed : 10 ml NS followed by 2 ml of 100 Units / ml heparin ( 200 units heparin ) each lumen Daily and PRN . Inspect site every shift . 19. Insulin Glargine 100 unit / mL Solution Sig : Four ( 4 ) units Subcutaneous at dinner time . 20. Insulin Lispro ( Human ) 100 unit / mL Cartridge Sig : One ( 1 ) Subcutaneous four times a day : As directed by sliding scale-please see attached scale . Discharge Disposition : Home Discharge Diagnosis : Primary diagnosis : Epidural abscess Secondary diagnosis : - colon cancer with mets to liver s/p resection 09-07 . - CAD s/p CABG x4 in ' 03 . - hypercholesterolemia - DM with neuropathy . - persistent R foot ulcer Discharge Condition : Stable , afebrile Discharge Instructions : You were diagnosed with an epidural abscess . Continue to take the antibiotics as directed . Take the pain medication as directed and do not drive while taking this medication . Call the doctor or return to the Thomas for : - fever > 102 - chest pain or shortness of breath - worsening pain or weakness in your legs , loss of bowel or bladder function or any other concerning symptoms . Followup Instructions : Please follow up with Dr. Scott Ann , MD Phone :( 921 ) 538 8079 on 2020-04-30 at 11:00am . Please follow up with Dr Erb - 3/30/07 at 10:00am . Please follow up with Dr. Rowles , your oncologist , in 2-3 weeks Brooke Donna MD 37-421 Completed by : Jessica POPE MD 58-704 2020-03-23 @ 1515 Signed electronically by : DR. Maryjane WS Hammond on : FRI 2020-05-01 12:36 AM ( End of Report )