Fever unspecified Dermatitis due to drugs and medicines taken internally Other specified pruritic conditions Cephalosporin group causing adverse effects in therapeutic use Knee joint replacement Benign essential hypertension Osteoarthrosis unspecified whether generalized or localized lower leg Aortic valve disorders Anemia of other chronic disease
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: MEDICINE
 
Allergies: 
Vancocin / Zosyn / ceftriaxone
 
Attending: ___.
 
Chief Complaint:
Fever, Drug Rash  
 
Major Surgical or Invasive Procedure:
None
 
History of Present Illness:
Mr. ___ is a ___ y/o male with a recently complicated history 
of 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 
___ and was discharged ___. In the past, he has  
had a prosthetic joint infection due to Proteus and CoNS, but 
during that last admission he has grown E. Coli, Enterococcus 
and Bacteroides. He was again admitted to ___ on ___ with 
fever to 102.7 at home. During this most recent hospitalization 
his fever was attributed to a drug reaction, thought to be from 
the zosyn. As a result his regimen was changed from daptomycin, 
metronidazole and ceftriaxone. He was discharged home on ___ 
after tolerating the regimen in the hospital. Yesterday however 
he noticed the start of a rash on his legs and arms that was 
erythematous and very pruritic. Today the rash worsened, has 
become more diffuse and he represented to the hospital for 
further evaluation.  
 
In the ED, initial vs were: 99.6, 108, 117/48, 16, 100% on RA. 
His labs showed a white count of 6.9 with 6% eosinophils, other 
labs were stable from his recent discharge. Exam was notable for 
fever and diffuse erythematous macular rash. He was given 
benadryl for presumed drug reaction and admitted for further 
evaluation. VS on transfer were: 102, 135/90, 103, 17, 100% on 
RA.  
  
On the floor initial VS were: 101.3, 116/44, 100, 20, 98% on RA. 
He currently only complains of extreme pruritis.  
 
Past Medical History:
Prosthetic Joint Infections  
Hypertension  
Osteoarthritis 
 
Social History:
___
Family History:
Positive for cancer, nonspecific  
 
Physical Exam:
Admission Physical Exam:
Vitals: 101.3, 116/44, 100, 20, 98% on RA  
General: Alert, oriented, no acute distress  
HEENT: MMM, oropharynx clear  
Neck: supple, no LAD  
Lungs: Clear to auscultation bilaterally, no wheezes, rales, 
ronchi  
CV: Regular rate and rhythm, +S1/S2, ___ systolic/diastolic 
murmur heard throughout the precordium  
Abdomen: soft, non-tender, non-distended, bowel sounds present, 
no rebound tenderness or guarding, no organomegaly  
GU: no foley  
Ext: Right knee flap with some erythema, site with small amount 
of serosanguinous drainage, does not appear infected  
Skin: diffuse erythematous macular rash  

Discharge Physical Exam (Pertinent):
Tm 99.0 Tc 97.2 BP 116/52 HR 76 RR 18 SpO2 100%/RA 
General: Alert, oriented, no acute distress  
CV: Regular rate and rhythm, +S1/S2, ___ systolic/diastolic 
murmur heard throughout the precordium  
Ext: Right knee flap with some erythema, site with small amount 
of serosanguinous drainage, does not appear infected  
Skin: no rash noted 
 
Pertinent Results:
Admission Labs:

___ 10:30AM BLOOD WBC-6.9 RBC-4.10* Hgb-10.7* Hct-33.6* 
MCV-82 MCH-26.2* MCHC-32.0 RDW-17.3* Plt ___
___ 10:30AM BLOOD Neuts-80* Bands-0 Lymphs-9* Monos-3 
Eos-6* Baso-0 Atyps-2* ___ Myelos-0
___ 10:30AM BLOOD Glucose-130* UreaN-12 Creat-1.2 Na-133 
K-3.4 Cl-96 HCO3-23 AnGap-17
___ 07:13AM BLOOD ALT-15 AST-21 AlkPhos-65 TotBili-0.5
___ 07:13AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.8

Blood cultures ___: No growth to date

Discharge Labs:
___ 07:10AM BLOOD WBC-4.1 RBC-3.49* Hgb-9.3* Hct-28.4* 
MCV-81* MCH-26.7* MCHC-32.8 RDW-16.7* Plt ___
___ 07:10AM BLOOD Glucose-94 UreaN-14 Creat-1.1 Na-137 
K-3.2* Cl-101 HCO3-26 AnGap-13
 
Brief Hospital Course:
Mr. ___ ia ___ y/o male s/p total knee replacement and 
multiple right knee surgeries now s/p Left rectus muscle free 
flap to right lower extremity complicated by infection with E. 
Coli, Enterococcus and Bacteroides recently discharged on 
daptomycin, ceftriaxone and metronidazole who presents with 
fever, rash and pruitis.  Fever and rash improved on monotherapy 
of tigecycline, but pruitis remained and pt refused taking 
antibiotics.  ID make recs to switch therapy to meropenem 500mg 
IV q6h and linezolid ___ mg q12h.  ID further narrowed coverage 
to meropenem 500 mg IV q12h since he had completed a full two 
week treatment for enterococcus.

#Drug Reaction:  Fever and pruitis is likely from the 
ceftriaxone given his recent reaction to the Beta-Lactam zosyn. 
Right knee flap does not appear infected at this time, and his 
presentation is very similar to his recent drug reaction. 
Discussed pt with ID as to what to change his antibiotic regimen 
to given his recent allergic reactions and polymicrobial 
infection. ID recommended switch to tigecycline and stopping 
prior antibiotic regimen.  Fever and rash improved on 
monotherapy of tigecycline, but pruitis remained and pt refused 
taking antibiotics.  ID make recs to switch therapy to meropenem 
500mg IV q6h and linezolid ___ mg q12h.  ID further narrowed 
coverage to meropenem 500 mg IV q12h since he had completed a 
full two week treatment for enterococcus.  Pt additionally 
received hydroxyzine for control of pruritis.

#Prosthetic Joint Infection:  No active signs of infections in 
right knee.  Patient will continue on meropenem on discharge 
home.

#Hypertension: blood pressure was well controlled on home HCTZ 
25mg daily dose.

Pt will follow up in the infectious disease clinic for 
antibiotic labs.

 
Medications on Admission:
1. ceftriaxone 1 gram q24h  
2. daptomycin 500 mg Q24H  
3. aspirin 81 mg once a day.  
4. acetaminophen 650 mg Q6H as needed for fever.  
5. enoxaparin 30 mg Q12H  
6. hydrochlorothiazide 25 mg once a day.  
7. oxycodone 5 mg Tablet Sig: ___ Tablets Q4H as needed for 
pain.  
8. metronidazole 500 mg Q8H  
 
Discharge Medications:
1. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1)  Subcutaneous 
Q12H (every 12 hours).  
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable 
PO DAILY (Daily).  
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 
6 hours) as needed for pain, fever.  
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO 
DAILY (Daily).  
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 
hours) as needed for pain.  
6. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical 
QID (4 times a day) as needed for itching.
Disp:*qs * Refills:*0*
7. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML 
Intravenous PRN (as needed) as needed for line flush.
Disp:*30 flushes* Refills:*0*
8. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) 
hours.
Disp:*24 Tablet(s)* Refills:*0*
9. meropenem 500 mg Recon Soln Sig: One (1) Recon Soln 
Intravenous Q6H (every 6 hours).
Disp:*120 Recon Soln(s)* Refills:*2*
10. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H 
(every 6 hours) as needed for itching.
Disp:*30 Tablet(s)* Refills:*1*
 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Drug rash
 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or 
wheelchair.
 
Discharge Instructions:
Mr. ___,

It was a pleasure taking care during your stay at ___ 
___.  You were admitted with a rash.  This 
was likely the result of a drug reaction.  Your antibiotics were 
changed and you improved.  You are now ready for discharge.

During the course of your hospitalization, the following changes 
were made to your medications:
- STOPPED flagyl
- STOPPED ceftriaxone
- STOPPED daptomycin
- STARTED Meropenem
- STARTED Hydroxyzine

You will need a few labs checked at your appointment next week 
because of your antibiotics.
 
Followup Instructions:
___

{'Fever': ['Dermatitis due to drugs and medicines taken internally', 'Cephalosporin group causing adverse effects in therapeutic use'], 'Drug Rash': ['Dermatitis due to drugs and medicines taken internally', 'Cephalosporin group causing adverse effects in therapeutic use'], 'Pruritis': ['Other specified pruritic conditions', 'Dermatitis due to drugs and medicines taken internally'], 'Knee joint replacement': ['Knee joint replacement'], 'Hypertension': ['Benign essential hypertension'], 'Osteoarthritis': ['Osteoarthritis', 'unspecified whether generalized or localized', 'lower leg'], 'Aortic valve disorders': ['Aortic valve disorders'], 'Anemia of other chronic disease': ['Anemia of other chronic disease']}