Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Gait disturbance, Haematocrit decreased, Haemoglobin decreased, Incisional drainage, International normalised ratio normal
Clinical narrative: Patient: DOB:  MRN:  Date: 8/8/2022 Room:      Chief Complaint:  R foot abscess   History Of Present Illness: Patient is a 68 y.o. male with a history of previous MRSA infection, presenting w/ R foot infection. Hit his R foot on lawnmower around mid July. Foot developed swelling, pain/ tenderness in affected area. Presented to the ED on 7/29 - xray neg, diagnosed w/ abscess s/p I&D at the ED, prescribed keflex and bactrim. Followed up for wound check on 7/31 - packing changed. Cx grew MRSA sensitive to Bactrim. Followed up on 8/5 - reported some redness, drainage; px prescribed norco for pain. Back at the ED today for wound check - open wound seems to have increased some in size w/ ?slough vs purulent drainage; surrounding cellulitis has also increased in size. Px reports significant pain in affected foot, having difficulty walking. He is compliant w/ antibiotics. CT showed edema w/o fluid collection, bone involvement.    ED work up also showed Covid 19 infection. Px reported subjective fever yesterday and chest congestion/ nonproductive cough for over a week. Denied known exposure to covid. + diffuse wheezing - also denied hx of COPD/ asthma but admits to tobacco abuse; has smoked >50 yrs and currently smoking 1 ppd.        Medical/Surgical/Family/Social History:   Past Medical History:  Patient  has a past medical history of MRSA infection (02/04/2022) and MRSA nasal colonization (10/13/2019).   Past Surgical History:  Patient's  has a past surgical history that includes Hx Broken/Fx Bones; Hx Thoracoscopy (Right, 2/12/2018); Hx Incision And Drainage (Right, 2/12/2018); Hx Arterial Line Insertion (Left, 2/12/2018); Hx Bronchoscopy (N/A, 2/12/2018); Hx Intercostal Nerve Block (Right, 2/12/2018); Thoracentesis (N/A, 2/8/2018); Ultrasound Guidance (N/A, 2/8/2018); and Hx Incision And Drainage (Left, 7/13/2015).   Family History:   Patient's family history includes Cancer in his mother; Diabetes in his father.      Social History:  He  reports no history of alcohol use.  He  reports current drug use. Drugs: Heroin, Fentanyl, IV, Marijuana, and Cocaine.  He  reports that he has been smoking. He has a 40.00 pack-year smoking history. He has never used smokeless tobacco.  Social History   Social History Narrative ? Not on file     Allergies:  Patient has no known allergies.   PTA Medications:   Prior to Admission Medications Prescriptions Last Dose Informant Patient Reported? Taking? HYDROcodone-acetaminophen (NORCO) 5-325 mg per tablet     No No Sig: Take 1 Tablet by mouth EVERY 6 TO 8 HOURS PRN for Pain for up to 3 days. cephALEXin (KEFLEX) 500 mg capsule     No No Sig: Take 1 Capsule by mouth Four times a day for 10 days. ibuprofen (MOTRIN) 800 mg tablet     No No Sig: Take 1 Tablet by mouth EVERY 6 TO 8 HOURS PRN for Pain. polyethylene glycol 3350 (MIRALAX) 17 gram packet     No No Sig: Take 17 g by mouth Daily. sulfamethoxazole-trimethoprim (BACTRIM DS) 800-160 mg per tablet     No No Sig: Take 1 Tablet by mouth Twice a day for 10 days.  Facility-Administered Medications: None     Review of Systems: Review of Systems Constitutional:  + subjective fever, no significant wt loss Eyes:   no changes in vision, no eye pain Ears, nose, mouth, throat, and face:  no ear pain, sore throat Respiratory:  +cough, chest congestion. no SOB Cardiovascular:  no palpitations, CP Gastrointestinal:  no n/v, diarrhea. no abdominal pain Genitourinary:  no dysuria, no urinary frequency Integument/breast:   no rash, no wound  Hematologic/lymphatic:  no hematemesis, hematochezia, melena, hematuria Musculoskeletal:   + R foot pain due to infection. no other joint/ muscle pain. Neurological:  no confusion. no focal weakness/ numbness Behavioral/Psych:  no anxiety, depression Endocrine:  no heat intolerance, no cold intolerance.     Physical Exam: Blood pressure (!) 195/90, pulse 58, temperature 98 °F (36.7 °C), temperature source Oral, resp. rate 17, weight 74.2 kg (163 lb 9.6 oz), SpO2 99 %. Physical Exam General Appearance: alert, no distress Lungs:  Diminished breath sounds w/ diffuse wheezing Heart:  regular rate and rhythm Extremities:  No significant leg edema. R anterior ankle w/ some edema, erythema, warmth, tenderness around the abscess. R foot wound as described above.  Pulses:  fair in UE HEENT: Normocephalic, without obvious abnormality. Anicteric sclerae. Neck: supple Back: negative Abdomen: no significant distention, soft, nontender Skin: no new rash  Neuro: awake, alert, no confusion     Data Review: CBC: Lab Results Component Value Date   WBC 5.1 08/08/2022   HGB 13.4 (L) 08/08/2022   HCT 39.8 08/08/2022   MCV 88.0 08/08/2022   CMP: Lab Results Component Value Date   SODIUM 136 08/08/2022   POTASSIUM 4.9 08/08/2022   MAGNESIUM 1.8 02/03/2022   PHOSPHORUS 2.8 02/03/2022   CHLORIDE 107 08/08/2022   CO2 22 08/08/2022   GLUCOSE 107 08/08/2022   BUN 23 08/08/2022   CREATININE 1.3 (H) 08/08/2022   CALCIUM 9.1 08/08/2022   TBILIRUBIN 0.3 08/08/2022   ALP 88 08/08/2022   AST 14 08/08/2022   ALBUMIN 3.8 08/08/2022     INR: Lab Results Component Value Date   INR 1.1 02/11/2018     Procalcitonin 0.44 LA 1.3     Imaging and Procedures: reviewed XR Ankle Right 3 VW   Result Date: 7/29/2022                                                         Radiology  PATIENT NAME:                      MR#:   PROCEDURE DATE:  07/29/2022                       ACCOUNT#:   ACCESSION #:                             ROOM#:   ORDERING PHYS:  Right ankle, 3 views  History:  Right ankle pain, fall, injury  There are no comparison studies.  There is moderate soft tissue edema greatest at the lateral malleolus and anterior ankle.  Degenerative changes are identified.  No fracture or dislocation.  Impression:  Moderate soft tissue edema at the level of the ankle as discussed.  No displaced fracture identified.               THIS IS AN ELECTRONICALLY VERIFIED REPORT              7/29/2022 2:37 PM:  MD   MD  DD:  07/29/2022 TD:  07/29/2022 JOB #:                                      Radiology Page 1    of   1                                                          COPY   CT Lower Extremity W Right   Result Date: 8/8/2022                                          Radiology  PATIENT NAME:                     MR#:  PROCEDURE DATE:  08/08/2022                       ACCOUNT#:  ACCESSION #:                             ROOM#:   ORDERING PHYS:    EXAM: CT right lower extremity  CLINICAL INDICATION:Right lower extremity injury  TECHNIQUE: Multiple axial CT images were obtained through the   right ankle with contrast.  75 mL, Isovue 370.  The axial CT data set was used to generate high resolution reformatted images in the coronal and sagittal planes to facilitate diagnostic accuracy and treatment planning.   Radiation dose reduction techniques were utilized on this exam.  COMPARISON: None.  FINDINGS: The bony mineralization is within normal limits.  The alignment of the osseous structures is anatomic.  There is no fracture, AVN or intraosseous destructive lesion.  There are degenerative changes of the ankle mortise. There is chondrocalcinosis within the ankle mortise.  There is a chronic osteochondral defect involving the medial talar dome.  There is edema of the anterior soft tissues of the ankle.  No discrete fluid collection.  No retained radiopaque foreign body.  No joint effusion.  IMPRESSION: Edema throughout the anterior soft tissues of the ankle without discrete fluid collection to suggest hematoma or abscess.  No evidence of acute bony injury.  Chronic deformities and degenerative change of the ankle.  CRITICAL RESULT: No.  COMMUNICATION: Per this written report.               THIS IS AN ELECTRONICALLY VERIFIED REPORT               8/8/2022 1:35 PM:  MD    MD   DD:  08/08/2022 TD:  08/08/2022 JOB #:                                    Radiology Page 1    of   1                                                          COPY       ASSESSMENT/PLAN: Problems: Principal Problem:   Cellulitis and abscess of right lower extremity Active Problems:   Acute exacerbation of chronic obstructive pulmonary disease (COPD)   Tobacco abuse   COVID-19 virus infection   Essential hypertension       Cellulitis and abscess of right lower extremity RLE cellulitis and abscess - failed outpt treatment - I&D on 7/29 + keflex/ bactrim - cx MRSA - IV vanco. Consult Gen Surg for possible I&D. Check A1c   Acute COPD exacerbation - new, COPD suspected considering sxs + smoking history. No fam hx of asthma. Will need outpt work up.  - IV steroids, duonebs, antibiotics. Titrate O2 inhal to keep O2 sat >92%. Mucinex, PEP tx for pulm hygiene.   Covid 19 infection - new. Px vaccinated but not boostered - CXR. Supportive care, Covid protocol. Will need negative pressure room due to need for nebs to treat COPD. Remdesivir not indicated at present. IVF ordered due to contrast exposure - crea higher today, on bactrim at home.    Tobacco abuse - nicotine patch. Smoking cessation encouraged.   Elevated BP, no hx of HTN - suspect Ess HTN. Prn hydralazine for now, will prob need maintenance med   DVT proph w/ heparin subcut   ---