Fever unspecified Penicillins causing adverse effects in therapeutic use Unspecified essential hypertension Osteoarthrosis localized not specified whether primary or secondary lower leg Leukocytopenia unspecified Unspecified glaucoma Unspecified pruritic disorder Anemia of other chronic disease Knee joint replacement
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Vancocin
 
Attending: ___.
 
Chief Complaint:
Fever
 
Major Surgical or Invasive Procedure:
Joint fluid aspiration and culture ___
 
History of Present Illness:
___ with HTN s/p multiple right knee surgeries, most recently 
complex right knee revision including megaprosthesis ___, 
c/b infection, and Left rectus muscle free flap to right lower 
extremity on ___. He was discharged ___. In the past, he has 
had PJI due to Proteus and CoNS, but during his last admission 
he has grown E. Coli, Enterococcus and Bacteroides. He is being 
followed by ID as an outpatient and is currently on a regimen of 
zosyn (via PICC) and PO rifampin.  
  
Pt presented to the ED today after a fever of 102.7 at home 
(takes his temp regularly). He denies any localizing 
signs/symptoms of infection including SOB, dysuria, 
headache/neck stiffness, abdominal pain, diarrhea, N/V, cough, 
or increased swelling or redness of the knee. He reports taking 
good PO intake.  
  
In the ED Ortho was consulted who felt no urgent intervention 
needed and will follow. CXR and UA were unremarkable. K+ was 
repleted, ESR/CRP added on, and pt was given 
nafcillin/ampicillin for possibility of endocarditis.
  
ROS: Denies headache, vision changes, rhinorrhea, congestion, 
sore throat, cough, shortness of breath, chest pain, abdominal 
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, 
hematochezia, dysuria, hematuria.  
 
Past Medical History:
Hypertension
OA of both knees
 
Social History:
___
Family History:
Positive for cancer, nonspecific.
 
Physical Exam:
Admission Exam: 
VS: T 98.7-99.6 BP 99-118/50-67 HR 91-100 RR ___ O2 Sat 96% RA 
 
GENERAL: NAD, affect somewhat blunted  
HEENT: NC/AT, EOMI, sclerae anicteric, MMM, OP clear.  
NECK: Supple, no JVD.  
HEART: RRR, harsh ___ systolic/diastolic murmur throughout the 
precordium, nl S1-S2.
LUNGS: CTA bilat  
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. Left 
sided vertical abdominal incision c/w recent rectus muscle graft 
c/d/i, no erythema or exudate  
EXTREMITIES: cool to touch, no c/c/e, 1+ peripheral pulses. 
There is a large muscle graft over the R knee which looks c/d/i. 
No tenderness or erythema/warmth. Right arm PICC is c/d/i 
without pain or erythema  
SKIN: No rashes or lesions.  
LYMPH: No cervical LAD.  
NEURO: Awake, A&Ox3, CNs II-XII intact, strength and sensation 
grossly intact

Discharge Exam:
VS: 98.5, 128/58, 88, 18, 100% RA  
GENERAL: NAD  
HEENT: NC/AT, EOMI, sclerae anicteric, MMM, OP clear.  
NECK: Supple, no JVD.  
HEART: RRR, harsh ___ systolic/diastolic murmur throughout the 
precordium, nl S1-S2. No splinters, oslers nodes, ___ 
lesions  
LUNGS: CTA bilat  
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding. Left 
sided vertical abdominal incision c/w recent rectus muscle graft 
 
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses. There is a 
large skin graft over the knee which looks c/d/i. No tenderness 
or erythema/warmth. 
SKIN: No rashes or lesions.  
LYMPH: No cervical LAD.  
NEURO: Awake, A&Ox3, CNs II-XII intact, muscle grossly intact  
 
Pertinent Results:
Admission Labs: 

___ 10:05PM   SED RATE-58*
___ 10:05PM   ___ PTT-28.1 ___
___ 10:05PM   NEUTS-74.5* LYMPHS-12.3* MONOS-6.0 EOS-6.5* 
BASOS-0.7
___ 10:05PM   WBC-3.6*# RBC-3.11* HGB-8.6* HCT-25.6* MCV-82 
MCH-27.6 MCHC-33.5 RDW-16.7*
___ 10:05PM   CRP-65.2*

R Knee AP/Lat/Oblique (___):
S/p right knee arthroplasty with hinge prosthesis, without 
evidence of 
loosening. Suspect joint effusion, though this is best 
corrrelated with 
physical exam. Small focus of subcutaneous emphysema noted. 

RUE Ultrasound (___):
No evidence of DVT in the right upper extremity

R Knee Ultrasound (___):
In the medial right knee, subjacent to the flap, there is a 
hypoechoic irregular collection measuring approximately 2.4 cm 
in greatest 
depth. In the sagittal plane, this measures approximately 1.0 cm 
in greatest depth. In the distal lateral right thigh, there is a 
heterogeneous hypoechoic collection measuring approximately 1.8 
x 3.5 cm in size, which is separate from the fluid on the medial 
side. 

CT Abd/Pelvis (___):
1. Prostatic hypertrophy with a hypodense peripheral zone, which 
is a 
nonspecific finding.  
2. No evidence of a drainable periprostatic or intraprostatic 
fluid 
collection.  
3. table renal and hepatic cysts.  
4. No free fluid. 

R Knee Aspirate (___):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 
      NO MICROORGANISMS SEEN. 
      FLUID CULTURE (Final ___:    NO GROWTH. 

Discharge Labs:

___ 05:50AM BLOOD WBC-4.7 RBC-3.28* Hgb-8.8* Hct-27.2* 
MCV-83 MCH-26.9* MCHC-32.4 RDW-17.2* Plt ___
___ 05:50AM BLOOD Glucose-107* UreaN-10 Creat-1.1 Na-136 
K-3.4 Cl-100 HCO3-26 AnGap-13
___ 04:46AM BLOOD ALT-37 AST-45* CK(CPK)-79 AlkPhos-67 
TotBili-0.___ y/o man with complicated right knee replacement history 
including multiple prosthetic joint infections s/p multiple 
revisions and washouts with recent muscle flap reconstruction 
presents from home with fever. In 
late ___, he was on Zosyn and Rifampin.  He presented this 
hospitalization with fever.  His knee was assessed by orthopedic 
surgery and thought not to be infected. Zosyn was stopped and 
the patient's fever resolved suggesting that he may have had a 
drug fever from Zosyn. Antibiotic regimen was adjusted to 
Daptomycin, Ceftriaxone, and Metronidazole which the patient 
tolerated well.

ACTIVE PROBLEM LIST:
# Drug Fever: Pt was on Zosyn for suppressive antibiotic 
coverage for PJI as outpatient and reported feeling febrile and 
experiencing chills, fever and severe pruritis with Zosyn 
infusions. He was documented to have fevers as an inpatient, not 
all of which coincided with Zosyn infusion. However, Zosyn was 
discontinued and the patient remained afebrile for the remainder 
of his hospital course. He had an extensive infectious workup 
and the R knee was exonerated as a possible source. Urine was 
clean and CXR was clear and blood cultures were negative at the 
time of discharge. There was concern for RUE DVT ___ inability 
to draw off the PICC, but RUE ultrasound was negative. 
Questionable prostatitis called on CT is unlikely given long 
term broad antibiotic coverage for all organisms that cause 
prostatitis and negative Gc/Ct assays. 

# History of R Knee prosthetic joint infections: Pt followed by 
ID; will require long term suppressive therapy to prevent 
recurrence of PJIs. Discharged on Daptomycin, Ceftriaxone, and 
Metronidazole, which the pt was tolerating well at the time of 
discahrge. He will follow up with Plastics and ID. 

INACTIVE ISSUES:
# Anemia: Pt's Hct remained at baseline throughout his hospital 
course. He had an anemia workup as outpatient that revealed 
likely ACD, consistent with recurrent PJI infections

# HTN: Pt was normotensive and hemodynamically stable throughout 
the hospital course. He was continued on his home HCTZ. 

# Leukopenia: Pt was leukopenic at the time of admission, 
resolved by discharge. Given the timecourse of his leukopenia, 
it is possible this was a manifestation of his systemic reaction 
to Zosyn. 

## Transitional Issues: 
Pt discharged home on Daptomycin, Ceftriaxone, and 
Metronidazole. He will require follow up with PCP, ___ 
___ and ID for his R knee. 
 
Medications on Admission:
-aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO  
DAILY (Daily).  
Disp:*45 Tablet, Chewable(s)* Refills:*0*  
-acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every  
6 hours) as needed for pain, HA, T>100 degrees: Max 12/day. Do  
not exceed 4gms/4000mgs of tylenol per day.  
-enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg  
Subcutaneous Q12H (every 12 hours).  
Disp:*60 syringes* Refills:*2*  
-hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO  
DAILY (Daily).  
-rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every  
12 hours).  
Disp:*60 Capsule(s)* Refills:*2*  
-oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)  
as needed for pain.  
-piperacillin-tazobactam-dextrs 4.5 gram/100 mL Piggyback Sig:  
4.5 grams Intravenous Q8H (every 8 hours).  
-diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H  
(every 6 hours) as needed for itching.  
 
Discharge Medications:
1. ceftriaxone in dextrose,iso-os 1 gram/50 mL Piggyback Sig: 
One (1) gram Intravenous Q24H (every 24 hours).
Disp:*30 gram* Refills:*0*
2. daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln 
Intravenous Q24H (every 24 hours).
Disp:*30 Recon Soln(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) 
Tablet, Delayed Release (E.C.) PO once a day.  
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 
6 hours) as needed for fever.  
5. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe 
Subcutaneous Q12H (every 12 hours).  
6. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once 
a day.  
7. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) 
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 
8 hours).
Disp:*90 Tablet(s)* Refills:*0*
 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- History of recurrent knee infection
- Drug Fever (Zosyn)

SECONDARY DIAGNOSES:
- Hypertension
- Anemia
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker 
or cane).
 
Discharge Instructions:
Mr. ___--

It was a pleasure taking care of you at ___ 
___.  You were admitted with fevers.  Given your 
history, there was concern that you had a worsening infection in 
your knee joint.  You were evaluated by medicine doctors and 
___.  You had cultures taken from your knee, which did not 
show any signs of infection.  Your antibiotics were changed and 
you improved.  You are now stable and ready for discharge.

During your hospital stay, the following changes were made to 
your medications: 
- STOPPED rifampin
- STOPPED zosyn
- STARTED daptomycin (to be given to you from home infusions)
- STARTED ceftriaxone (to be given to you from home infusions)
- STARTED flagyl (an oral antibiotic)
 
Followup Instructions:
___

{'Fever': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Penicillins causing adverse effects in therapeutic use': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Unspecified essential hypertension': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Osteoarthrosis': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Leukocytopenia': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Anemia of other chronic disease': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement'], 'Knee joint replacement': ['Fever', 'Penicillins causing adverse effects in therapeutic use', 'Unspecified essential hypertension', 'Osteoarthrosis', 'Leukocytopenia', 'Anemia of other chronic disease', 'Knee joint replacement']}