DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: A patient with stump pain and fever following above-knee amputation.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with history of non-insulin-dependent diabetes mellitus and history of left great toe amputation, who developed osteomyelitis of the left foot requiring left below-the-knee amputation approximately 20 months ago. The patient developed a wound over the left below-the-knee amputation stump approximately four or five weeks ago. He started having drainage and increasing pain. The patient was brought to the emergency room. He was seen by Dr. Jane Doe, and he underwent left above-the-knee amputation for nonhealing amputation of left below-the-knee amputation stump secondary to osteomyelitis. The patient’s blood cultures revealed Staphylococcus aureus. He was recently discharged from the hospital. He developed candiduria. He also had presumptive pneumonia. The patient was discharged on ciprofloxacin as well. The patient is now readmitted with a three-day history of subjective fever. His temperature was 102.5, but he was defervesced since admission. His chief complaint appears to be left stump pain, but he denies any sore throat, rhinorrhea, earaches, cough, chest pain. No shortness of breath, no nausea, vomiting, or diarrhea. No urinary symptomatology, including dysuria, polyuria or urinary urgency. No hematuria. No myalgias or arthralgias. The patient’s WBC is actually within normal limits, and the patient just had one temperature on admission, and he has been afebrile seen then.
PAST MEDICAL HISTORY: Significant for left below-the-knee amputation 20 months ago, left great toe amputation for diagnosis of osteomyelitis of the left foot. The patient is status post above-the-knee amputation of the left lower limb because of nonhealing amputation as well as osteomyelitis.
CURRENT MEDICATIONS: Include Glucophage, Avandia, Vasotec, and Lortab. He was also taking Cipro, and he ran out of Diflucan on Thursday.
ALLERGIES: NKDA.
FAMILY HISTORY: Unremarkable.
SOCIAL HISTORY: No history of alcohol abuse or smoking.
REVIEW OF SYSTEMS: The patient denies any hearing loss, photophobia, blurred vision, denies any sore throat. No dysphasia. No aphasia. No nausea, vomiting, diarrhea, constipation, hematemesis or hematochezia. He denies any dysuria or polyuria. He denies hematuria. No chest pain, shortness of breath, PND or orthopnea. No hemoptysis. No myalgias or arthralgias, but he does have pain of his stump. No history of blood dyscrasia or bleeding disorder.
PHYSICAL EXAMINATION:
VITAL SIGNS: T-max 102.5; now, it is 98.6; pulse 64; respiratory rate 20; and blood pressure 94/64.
GENERAL: The patient is a well-developed, well-nourished Hispanic male, in no acute distress.
HEENT: Pupils are equal and reactive to light. Extraocular muscles are intact. Oropharynx, no evidence of oral thrush.
NECK: Supple. No thyromegaly. Trachea midline.
LUNGS: Clear to auscultation and percussion. No wheeze, rhonchi or wheezing.
HEART: Normal rate and rhythm, normal S1, S2. No murmur, gallop, rub, thrills or heaves.
ABDOMEN: Soft, no rigidity, guarding or rebound. No hepatosplenomegaly. Positive bowel sounds.
EXTREMITIES: Show left below-the-knee amputation stump, tender to palpation. At this time, it does not have any redness, wound separation or drainage.
SKIN: The skin temperature appears normal. Skin has no evidence of rash.
LYMPHATICS: Reveal no palpable cervical or axillary lymphadenopathy.
LABORATORY DATA: WBC is 5.2, hemoglobin 10.8, and platelet count 284.
IMPRESSION:
1. Fever. Considerations are:
a. Fungemia.
b. Pulmonary, rule out pneumonia.
c. Urinary tract infection.
d. Secondary to stump hematoma versus abscess, evaluate if drug related.
2. Status post above-the-knee amputation of left lower limb for nonhealing amputation and osteomyelitis.
3. Non-insulin-dependent diabetes mellitus.
4. Status post below-the-knee amputation 20 months ago.
5. Status post fall approximately one week prior to his recent hospitalization.
6. History of chronic osteomyelitis of the left foot.
7. Status post amputation of the left great toe.
8. History of hypertension.
The patient recently was diagnosed with osteomyelitis, nonhealing amputation left below-the-knee, for which he required above-the-knee amputation of the left lower limb. Cultures grew Staphylococcus aureus. He had postoperative fever. He was discharged home on Cipro for possible pneumonia as well as Diflucan for candiduria. He now presents with three-day history of fever. No clear etiology other than this significant pain over the stump. Therefore, need to rule out abscess versus infected hematoma. He has defervesced, and his white count is within normal limits. He does not appear septic or toxic. Therefore, we will not reinitiate antibiotics until further workup, including blood, urine cultures, and MRI of the left above-the-knee amputation stump.
RECOMMENDATIONS:
1. We agree with MRI of the left above-the-knee amputation stump.
2. Blood cultures sent for culture and sensitivity.
3. UA, C and S.
4. Follow CBC with differential.
5. Chest x-ray.
6. Hold antibiotics for now depending on above evaluation.
