Infection following a procedure initial encounter Other specified local infections of the skin and subcutaneous tissue Enterococcus as the cause of diseases classified elsewhere Methicillin susceptible Staphylococcus aureus infection as the cause of diseases classified elsewhere Other surgical procedures as the cause of abnormal reaction of the patient or of later complication without mention of misadventure at the time of the procedure Other place in single-family (private) house as the place of occurrence of the external cause Other nail disorders Rheumatoid arthritis unspecified Essential (primary) hypertension Gastro-esophageal reflux disease without esophagitis Inflamed seborrheic keratosis Other specified disorders of muscle
 
Name:  ___               Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
R IF pain 
 
Major Surgical or Invasive Procedure:
PROCEDURE:  Irrigation, washout and debridement right index
finger distal interphalangeal joint.
 
History of Present Illness:
___ year-old right-hand dominant nurse at ___ with severe RA on methotrexate who underwent excision 
of
distal right IF mass just proximal to eponychial fold concerning
for mucus cyst on ___ at ___. She noted some drainage 
from
the incision starting in the past ___, she had worsening pain
therefore went to ___ earlier today where they
cultured purulent discharge and GPCs in clusters and pairs were
observed on gram stain, gave vancomycin and zosyn, and was
superficially washed out and digital block performed for pain
control. She was transferred to ___ for further management. 
She
denies fevers or chills, only increasing pain, drainage, and
swelling of the digit.  
 
Past Medical History:
RA
 
Social History:
___
Family History:
non contributory 
 
Physical Exam:
***
 
Pertinent Results:
___ 02:26PM   WBC-8.9 RBC-3.94 HGB-12.5 HCT-37.7 MCV-96 
MCH-31.7 MCHC-33.2 RDW-13.1 RDWSD-45.1
 
Brief Hospital Course:
This is a delightful ___ female nurse ___ 
___ who is on immunosuppressants for rheumatoid 
arthritis.  She underwent excision of a draining mucous cyst by 
Dr. ___  ___ unfortunately she developed an infection at 
the surgical site.  She was admitted to the hospital yesterday 
and underwent bedside I&D x2. 

The patient was formally admitted to hand service for ongoing 
observation as well as IV antibiotic
treatment.  She was placed on vancomycin and Unasyn. Her 
cultures from the OSH grew pan sensitive enterococcus and MSSA 
(resistant to b lactams) she was discharged on levofloxacin. She 
will follow up with Dr. ___ in clinic as 
scheduled. 
 
Discharge Medications:
1.  Acetaminophen 650 mg PO Q6H:PRN Pain - Mild  
2.  Levofloxacin
 
Discharge Disposition:
Home
 
Discharge Diagnosis:
R IF wound infection 

 
Discharge Condition:
AVSS, AOx3

 
Discharge Instructions:
You were admitted to the ED with a wound infection. Please 
follow this instructions for postoperative care: 

1. Soak your wound four times daily in warm soapy water. After 
this, replace the dressing. 

2. Take your antibiotics as prescribed

3. Only take narcotic pain medications for sever pain and do not 
drive while taking these medications 
 
Followup Instructions:
___

{'R IF pain': ['Infection following a procedure', 'Other specified local infections of the skin and subcutaneous tissue'], 'drainage': ['Infection following a procedure', 'Other specified local infections of the skin and subcutaneous tissue'], 'worsening pain': ['Infection following a procedure', 'Other specified local infections of the skin and subcutaneous tissue'], 'swelling of the digit': ['Infection following a procedure', 'Other specified local infections of the skin and subcutaneous tissue']}