Other and unspecified disc disorder lumbar region Unspecified osteomyelitis other specified sites Anxiety state unspecified Depressive disorder not elsewhere classified Obstructive sleep apnea (adult)(pediatric) Other chronic pain Displacement of lumbar intervertebral disc without myelopathy Tobacco use disorder Hip joint replacement
 
Name:  ___                  Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Vancomycin
 
Attending: ___.
 
Chief Complaint:
Back Pain
 
Major Surgical or Invasive Procedure:
___ guided vertebral and disc biopsy at L5-S1.

 
History of Present Illness:
___ yo man w/ R. hip MSSA septic arthritis w/ iliopsoas absces in 
___ treated w/ I&D & 12 weeks nafcillin w/ -TTE. Persistent 
osteoarthritis w/ total R. hip replacement on ___ w/ 
continued pain. Developed worsening low back, groin, and 
anterior/lateral right leg pain and was seen by Ortho on 
___, at which time labs were notable for ESR 6 and CRP 1.8. 
He had a bone scan on ___, which showed mild increased 
activity at the right hip arthroplasty. Treated with Prednisone 
taper on ___ for presumed hip flexor tendinitis with no 
relief. Referred to Pain clinic, where he was started on 
Tizanidine and an MRI was ordered. Non-contrast MRI on ___ 
showed progression of disc disease at L5-S1 and high T2 signal 
within the disc and new edema in the endplates. The MRI was
repeated with contrast ___, which showed abnormal 
enhancement of L5-S1 and the anterior paraspinal soft tissues 
consistent with spondylodiscitis without radiographic evidence 
of abscess or bone destruction. Patient was referred to ___ 
clinic for further evaluation. Given history of infectious in 
setting of patient w/ intermittent fevers to 101.0 and worsening 
night sweats, ID was concerned for osteomyelitis. Mr. ___ 
was scheduled for bone biopsy outpatient, but was unable to wait 
when his procedure was delayed. Given concern for infection and 
initial delay in biopsy, he was admitted to accelerate the 
biopsy.   
  
ROS
(+) per HPI. Intermittent fevers to 101.0, self resolve
(-) denies chills, 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:
-Chronic low back pain ___ L5-S1 disc bulge
-OSA- no longer on CPAP
-Anxiety
-Depression
- Open appendectomy. 
- Psoas abscess debridement on ___
 
Social History:
___
Family History:
Father died due to alcoholism and CHF. Mother, brother, and 
sister are alive and well. 
 
Physical Exam:
Admission Physical Exam 
VS: 98.5, 119/72, 84, 18, 98RA 
GEN Alert, oriented, no acute distress  
HEENT NCAT MMM EOMI sclera anicteric, OP clear  
NECK supple no LAD  
PULM CTAB no wheezes, rales, ronchi  
CV RRR normal S1/S2, no mrg  
ABD soft NT ND normoactive bowel sounds, no r/g  
EXT WWP 2+ pulses palpable bilaterally, no c/c/e  
NEURO CNs2-12 intact, negative straight leg raise, 2+ reflexes 
throughout, gait normal, strength ___ throughout, sensation 
grossly intact throughout  
SKIN no lesions 

Discharge Physical Exam:
VS: 98.3, 124/75, 65, 18, 98%RA 
GEN Alert, oriented, no acute distress  
HEENT NCAT MMM OP clear  
NECK supple no LAD  
PULM CTAB no adventitious breath sounds  
CV RRR normal S1/S2, no mrg  
ABD soft NT ND normoactive bowel sounds, no r/g 
Back: Pain to palpation over lumbar/sacral spine, soreness at 
biopsy site, no erythema or edema noted at site.  
EXT WWP 2+ pulses palpable bilaterally, no c/c/e  
NEURO No focal neurological deficits, AOx3
SKIN no lesions
 
Pertinent Results:
Admission labs
___ 07:00AM BLOOD WBC-9.9 RBC-5.00 Hgb-15.4 Hct-45.1 MCV-90 
MCH-30.9 MCHC-34.2 RDW-13.4 Plt ___
___ 07:00AM BLOOD ___ PTT-32.4 ___
___ 07:00AM BLOOD Glucose-84 UreaN-13 Creat-0.9 Na-143 
K-4.4 Cl-108 HCO3-23 AnGap-16

Post-Operative labs:
___ 08:00AM BLOOD WBC-11.9* RBC-5.23 Hgb-15.9 Hct-47.3 
MCV-90 MCH-30.4 MCHC-33.6 RDW-13.0 Plt ___

___ 2:13 pm TISSUE      Source: vertebrae and disc. 
      EXTRA SWABS RECEIVED, NOT USED PER ___ 1833 
___. 

   GRAM STAIN (Final ___: 
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 
      NO MICROORGANISMS SEEN. 

   TISSUE (Preliminary):    NO GROWTH. 

   ANAEROBIC CULTURE (Preliminary): 

   FUNGAL CULTURE (Preliminary): 

   POTASSIUM HYDROXIDE PREPARATION (Final ___: 
      NO FUNGAL ELEMENTS SEEN. 

   ACID FAST CULTURE (Preliminary): 

   ACID FAST SMEAR (Final ___: 
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
 
Brief Hospital Course:
# Bone/disc Biopsy/Vertebral Osteomyelitis: Worsening back pain 
in setting of previous history of R. hip infections now w/ MRI 
suggestive of spondylodiscitis unable to r/o infection. 1 month 
w/ intermittent fevers to Tmax 101.0 and reported night sweats, 
no luekocytosis, blood cx -, UA -, biopsy gram stain -. If 
infectious etiology, most likely hematogenous spread given lack 
of tissue involvement connecting hip to L5-S1 space, cant r/o 
possibility of R. hip involvement. Vertebral and disc Biopsy at 
level of L5-S1 was performed under ___ guidance w/o complication 
and sent for culture, gram stain, and PCR. Post-operatively, Mr. 
___ had mild back tenderness which responded well to lose 
dose oxycodone. No new neurological deficits, back pain stable, 
wound site clean w/o concern for infection. Patient discharged 
with appropriate infectious disease follow up for pending 
cultures.   

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q8H:PRN pain 
2. Tizanidine 4 mg PO TID pain 
3. Gabapentin 300 mg PO TID pain 

 
Discharge Medications:
1. Gabapentin 300 mg PO TID pain 
2. Ibuprofen 400 mg PO Q8H:PRN pain 
3. Tizanidine 4 mg PO TID pain 
4. OxycoDONE (Immediate Release)  5 mg PO Q6H:PRN pain 
RX *oxycodone 5 mg 1 tablet(s) by mouth q6H PRN pain Disp #*15 
Tablet Refills:*0

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Low Back Pain

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.

 
Discharge Instructions:
Mr. ___,

It was a pleasure taking care of you while you were at ___ 
___.

You came into the hospital for an image guided biopsy of your 
vertebrae and disc after CT imaging revealed worsening disc 
disease which was felt could represent an infection. Infection 
was a concern because of your previous history of infection as 
well as your symptoms of worsening back pain, intermittent 
fevers, and night sweats. 

A CT guided biopsy was performed and cultures were sent to test 
for infection. These studies will take a couple days to come 
back and some of the results will take longer. It will be 
important that you follow up with your infectious disease 
doctor. Also, please follow up with your pain management doctor 
to help get better control of your back pain. 

Thank you  
 
Followup Instructions:
___

{'Back Pain': ['Other chronic pain', 'Displacement of lumbar intervertebral disc without myelopathy'], 'Fever': ['Unspecified osteomyelitis', 'other specified sites'], 'Night Sweats': ['Unspecified osteomyelitis', 'other specified sites'], 'Anxiety': ['Anxiety state', 'unspecified'], 'Depression': ['Depressive disorder', 'not elsewhere classified'], 'Sleep Apnea': ['Obstructive sleep apnea (adult)(pediatric)'], 'Pain': ['Other chronic pain'], 'Disc Disease': ['Other and unspecified disc disorder', 'lumbar region']}