Date of Admission: 11/8/2023   Date of Discharge: 11/12/2023   Issues to be Addressed at Follow-up: 1. Continue home antibiotic infusion until 11/29/23 2. Follow up with PCP for optimization of insulin regimen and diabetes 3. Follow up with wound care clinic for dressing change 4. Follow up with infectious disease doctor for antibiotic follow up   Pending Study Results at Discharge:  Unresulted Lab Orders    Date and Time Order Name Status Specimen Source   11/8/2023 11:07 PM BLOOD CULTURE 2 Preliminary BLOOD   11/8/2023 11:15 AM BLOOD CULTURE Preliminary BLOOD       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) STAPH AUREUS BACTEREMIA   ? SCALP ABSCESS   ? CELLULITIS       11/8/2022 TAV 5 days of pain, swelling and area feels hot. Feels it is becoming worse. Pain is 6/10, worse with opening mouth, very tender  No fever.  Thinks it might be insect bite but did not see any insects.     A/P - appears to be a cellulitis from unclear cause Plan - Rocephin, antibiotics, Tylenol, f/u PRN     ? COVID-19 DISEASE   ? DM 2       11/8/2022 TAV AM blood sugars are 230-280 in the morning,  On metformin 2,250 and Actos 30mg.   Pt also lost 100lbs over 1-2 years.  Current weight is 300lbs last few month.   A/P - Diabetes Plan - labs, pt to monitor sugars before breakfast and before dinner, pt to have follow up.     ? OBSTRUCTIVE SLEEP APNEA       Date: 2/8/19  Study Type: WatchPat   pAHI: 25.7  BMI: 52.08   ESS: 2  Min SpO2: 69% SpO2<90%: 33.2 minutes Moderate Sleep Apnea.   ? SEVERE OBESITY (BMI >= 40)   ? HTN (HYPERTENSION)     Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home with Home Health   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   History of Present Illness per Dr.:   40 year old male with known DM, OSA now presenting with left sided facial/ scalp swelling. Patient feels like he had a bug bite or hair follicle irritation and started scratching it.  He developed redness and warmth on the side of his head, applied warm compresses . Then wound started to drain pus. He then developed swelling around his left eye.  No changes in vision or pain with eye movement.  Patient was seen in ED on 11/6, given IV abx then bactrim on discharge.  Patient presenting today with persistent redness and facial swelling.  No fever at home.  No NV.  No CP, palpations or SOB.  COVID Positive in ED - asymptomatic.   At baseline: Independent in ADL. Works at as engineer   Hospital Course and Significant Findings: 40 Y male with T2DM on metformin and actos, OSA with recent bug bite on left side of scalp and recent ED visit for cellulitis with failed bactrim therapy admitted for scalp cellulitis with some preseptal/orbital involvement, s/p I &D in the ED, noted to have MSSA bacteremia. He was treated with IV Zosyn followed by IV Unasyn and transitioned to IV Cefazolin 2g Q8H per ID recommendations. TTE was done and ruled out endocarditis. Repeat blood cultures negative and wound cultures with MSSA. HNS consulted given persistent drainage of abscess and recommended wick placement and dressing to allow maximum drainage. Patient has uncontrolled diabetes mellitus with A1C of 11.6 and managed with insulin regimen. Currently patient stable for discharge home with home antibiotic infusion (until 11/29/23) via midline with close ID, wound care, PCP follow up. Discharged on insulin given uncontrolled diabetes and active infection. Metformin not restarted due to risk of lactic acidosis in sepsis. Insulin teaching provided.   Of note, patient had incidental COVID 19 on admission likely from prior infection given recent URI and cycle threshold of PCR >35. No need for covid therapy or precautions at this time.   Patient Active Hospital Problem List:  CELLULITIS (11/8/2022)  SCALP ABSCESS (11/8/2023) STAPH AUREUS BACTEREMIA 1/2 bottle 11/7/23   Assessment: Bug bite 2 weeks back, with scratching leading to pain and swelling over last 1 week. Denied fevers, chills. Did not improve with outpatient antibiotic therpay with bactrim. Scalp abscess noted s/p I & D in the ED. CT head and orbit on 11/7/23 with left sided preseptal orbital cellulitis   Plan: - mild leukocytosis to 11.5 which has since then resolved - f/u BCx- prelim negative X 3 days - f/u wound culture- final confirmed as MSSA - SA bacteremia in 1/2 bottles- MSSA - s/p Zosyn (11/8-11/10), s/p Unasyn (11/11) - started on cefazolin on 11/12/23 for 4 week IV antibiotic course (until 11/29/23 via midline) - appreciate ID recommendations - appreciate HNS recommendations - wound care recommendations appreciated -TTE normal - need midline  placement for IV antibiotics prior to discharge  - not a candidate for ACAH as lives where family resides      DM 2 (2/19/2019)   Assessment: Diagnosed at age of 25 years. Uncontrolled. On metformin and actos at home. Ran out of actos few days prior to admission          Lab Results Component Value Date   Hgb A1c % 11.6 (H) 11/08/2023            Lab Results Component Value Date   GLUCOSE, RANDOM 305 (H) 11/12/2023   GLUCOSE, RANDOM 267 (H) 11/11/2023   GLUCOSE, RANDOM 349 (H) 11/10/2023            GLUCOSE, BLOOD, GLUCOMETER Date/Time Value Ref Range Status 11/12/2023 0645 266 (H) 60 - 159 mg/dL Final 11/12/2023 0032 380 (H) 60 - 159 mg/dL Final 11/11/2023 2232 415 (H) 60 - 159 mg/dL Final 11/11/2023 1828 438 (H) 60 - 159 mg/dL Final 11/11/2023 1226 347 (H) 60 - 159 mg/dL Final 11/11/2023 0617 269 (H) 60 - 159 mg/dL Final 11/10/2023 2205 297 (H) 60 - 159 mg/dL Final 11/10/2023 1735 381 (H) 60 - 159 mg/dL Final 11/10/2023 1201 306 (H) 60 - 159 mg/dL Final      Plan:  - Continue ISS - worried about hypoglycemia symptoms; keep juice/candy at bedside per patient request (for emergencies) - FSG Q6H per patient request - Hold metformin and actos - Continued optimization as outpatient - increase lantus to 30 units qhs - increase Lispro 8 units TID AC - amenable to staying on insulin on discharge with outpatient follow up with PCP and diabetologist - interested in starting ozempic on discharge - need recup insulin teaching prior to discharge    HTN (HYPERTENSION) (8/7/2017)   Assessment: noted   Plan:  - continue lisinopril   SEVERE OBESITY (BMI >= 40) (8/8/2017)  OBSTRUCTIVE SLEEP APNEA (2/11/2019) Assessment: Noted Plan: - CPAP qhs and during naps - outpatient follow up   COVID-19 DISEASE (1/7/2022)   Assessment: noted, asymptomatic. Had recent URI 3 weeks back and COVID PCR Ct>35.    Plan:  - covid precautions discontinued by IP     Primary Procedures:  None   Secondary Procedures: INCISION AND DRAINAGE   Reason for Hospital Admission (Admitting Diagnosis):  Scalp abscess and scalp/preseptal cellulitis   Complications: none   Consults:  HOSPITAL MEDICINE - INITIAL INPATIENT CONSULTATION. HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code      Note Details  Author (M.D.) File Time 11/12/2023  2:40 PM Author Type Physician Status Signed Last Editor (M.D.) Specialty Hospital Medicine Hospital Acct # Admit Date 11/8/2023  ED to Hosp-Admission (Discharged) on 11/8/2023  ED to Hosp-Admission (Discharged) on 11/8/2023   Routing History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders Procedures   Flowsheets   Forms:   STATUS FORM  Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   HTN (HYPERTENSION)  SEVERE OBESITY (BMI >= 40)  OBSTRUCTIVE SLEEP APNEA  DM 2  STAPH AUREUS BACTEREMIA  COVID-19 DISEASE  CELLULITIS  SCALP ABSCESS Care Timeline  11/08   Admitted from ED (Observation) 1935 11/10   Admitted 1135 11/12   Discharged 2230  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 11/12/2023) Medication List at Discharge   albuterol sulfate 90 mcg/actuation 2 Puffs Inhalation EVERY 4 HOURS AS NEEDED, . 100 days supply for asthma is 1 canister  blood sugar diagnostic 1 Strip Miscell. (Med.Supl.;Non-Drugs) 2 TIMES A DAY, to measure blood sugar  blood-glucose control, normal Use as directed with blood glucose meter  blood-glucose meter Use as directed to test blood sugar  cefazolin sodium   10 gram Recon soln, Infuse 2 g intravenously, push over 5 minutes every 8 hours, as directed for infection. Compounded by pharmacy. Therapy to continue until 11/29/23 (date). Home infusion pharmacists to order flush and lab per protocol/guidelines for this drug therapy. (Note: Therapy end date is as noted above. Not system end date).  10 gram Recon soln, ceFAZolin 2 g/SWFI 20 mL SYRINGE: Infuse 2 g intravenously, push over 5 minutes every 8 hours, as directed for infection. Compounded by pharmacy  hydrocodone/acetaminophen 5-325 mg 1 tablet Oral EVERY 4 HOURS AS NEEDED  inhaler,assist device,lg mask Use as directed with inhaler  insulin glargine-yfgn 30 Units Subcutaneous EVERY BEDTIME  insulin lispro 8 Units Subcutaneous 3 TIMES A DAY BEFORE MEALS  lancets 30 gauge 1 Each Miscell. (Med.Supl.;Non-Drugs) 2 TIMES A DAY, to measure blood sugar  lisinopril 10 mg Oral DAILY  sodium chloride 0.9 % (flush) 0.9% Sodium chloride 0.9 % 10 mL BD POSIFLUSH SYRINGE: Flush catheter with 10 mL before and after medication infusion. Flush all lumens every 12 hours with 10 mL, or as directed by RN  syringe-needle,insulin,0.5 mL 1/2 mL 31 gauge x 15/64" Use as directed with insulin