Age: 23.0
Sex: M
Vaccine: FLU4, PPV
Symptoms: Nausea, Pain in extremity, Peripheral swelling, Pyrexia, Red blood cell sedimentation rate increased
Clinical narrative: Cellulitis. Pt is a 23-year-old gentleman who has a history of type 1 diabetes diagnosed at two years of age. He has had multiple admissions for DKA and abdominal pain periodically. The last being in August of this year. Sometimes his abdominal pain is related to DKA, sometimes due to what is felt to be chronic pancreatitis and/or his hepatomegaly from poorly controlled diabetes. At his last admission patient pt was in hospital for prolonged period of time with persistent abdominal pain despite negative amylase and lipase. He gradually improved requiring Dobhoff feedings and PCA pump for analgesia. Since that admission, the patient has seen Dr. and was taken off of LYRICA and since then his abdominal pain is resolved. Dr. felt that the LYRICA was causing his hepatic pain. Patient's however, is on gabapentin for his peripheral neuropathy. He was seen earlier in the week for follow-up of his peripheral neuropathy which was really quite severe despite being on gabapentin 300 mg 3 tablets 3 times a day as well as and CYMBALTA and his CYMBALTA was increased to 60 mg twice a day and amitriptyline 50 mg by mouth daily at bedtime was added to his regimen. This really helped his peripheral neuropathy and patient was given a flu shot and pneumococcal vaccine in his right arm at the same time. That evening he began to note is a little bit of discomfort in the right arm. By the following day he was having severe pain in the right arm and by the morning time noted this area of redness and induration which he outlined with an ink pen. By later that afternoon, the pain was very severe and he went to the emergency room. While there he had a full investigation including blood cultures, CBC, CRP, sedimentation rate, x-ray of his arm. An ultrasound of the arm to rule out abscess formation, all of which were negative. Blood cultures remain negative. He has had some fever and states that he has a cough and some feelings of weakness and fatigue. His blood sugars up and around 200. He did not have ketones when evaluated in the emergency room. Patient was given IV clindamycin and oral clindamycin was given by prescription, which he has taken since then and presents now for follow-up. The area of induration was marked out with ink on his right arm. It has extended and some areas up to a centimeter beyond that at this point. It's exquisitely tender to touch and he also notices some pain in the right axilla as well. When seen yesterday on 10/12/17, ZITHROMAX was added to his regimen. His laboratory studies were repeated and a chest x-ray was obtained. The chest x-ray was normal. His labs showed an elevated CRP of 8.6. His SGOT was 2574 and ALT was 965. His sedimentation rate was elevated at 48. His CBC showed a white count of 5.1, hemoglobin is 13.5 and blood cultures from his emergency room visit, have remained negative. Patient this morning is actually feeling a little stronger. He is not as nauseous and is keeping food down but his arm pain is worsening and is more swollen and the erythema has spread even further beyond his inked out margins. The patient did state that his compliance has been better. He had been drinking occasionally using chewing tobacco and his diabetic control has been difficult. Patient does go into DKA very quickly at times and has somewhat brittle diabetes. His last hemoglobin A1C in May was over 10. Typically it is 11 or better. He is in the process of getting follow-up with Dr. He states however that since his last admission he basically lived at home with his parents. He goes to work and comes home. He does not hang out with his friends who expect him to drink and do other activities. He states that he has been absent from alcohol and tobacco. His abdominal pain has essentially resolved after discontinuing LYRICA. He has not had vomiting, but does feel nauseous. No fever, or chills. No chest pain or shortness of breath. No trauma.