DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Pain and swelling in pannus.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with diabetes mellitus and history of staph skin abscess, who presents with a one-day history of pain and swelling of the pannus and a fever to 104 degrees Fahrenheit. The patient reports chills but no nausea or vomiting. In the emergency department, Surgery was consulted, and a CT and abdominal ultrasound were done to rule out necrotizing fasciitis. Both the CT and abdominal ultrasound showed no evidence of necrotizing fasciitis. The patient was started on vancomycin and Zosyn. Metformin was held secondary to IV contrast given for the CT scan.
PAST MEDICAL HISTORY:
1. Diabetes mellitus. The patient is on metformin and glipizide as an outpatient. He reports hemoglobin A1c in the 6-7 range.
2. Hypertension.
3. Hypercholesterolemia.
4. History of staph skin infection, requiring antibiotics.
5. Obesity.
6. Sarcoidosis.
MEDICATIONS: Metformin, glipizide, Zocor, and lisinopril.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married and has two children. He denies smoking, drinking alcohol or use of any illicit drugs.
FAMILY HISTORY: The patient’s father and paternal grandfather both have diabetes mellitus, and the patient’s mother and maternal grandmother both had coronary artery disease.
REVIEW OF SYSTEMS: Negative, except as above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 112/62, heart rate 130, respiratory rate 18, oxygen saturation 95% on room air, and temperature is 39.6 Celsius.
GENERAL: The patient is in no acute distress. He is pleasant and articulate.
HEENT: Pupils are equal, round, and reactive to light. No lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: The patient is tachycardic, without murmurs.
ABDOMEN: Obese with large hanging pannus. Overhanging portion of pannus is red and warm. One area of induration is 8.5 cm x 10.5 cm without fluctuance at the lower right end of pannus. No exudates.
EXTREMITIES: Warm and well perfused.
SKIN: No other active lesions.
LABORATORY DATA: White blood cell count is 11.4 with 77% segs, hemoglobin 16.2, hematocrit 47.8, and platelets 128,000. C-reactive protein 7.4, sodium 134, potassium 4, chloride 102, bicarbonate 22, BUN 12, creatinine 0.9, and glucose 258.
IMAGING: A CT of the abdomen and pelvis with IV contrast showed mild skin thickening along the inferior aspect of the pannus compatible with the patient’s history of soft tissue infection. There is no underlying abscess.
ASSESSMENT AND PLAN: This is a (XX)-year-old male, diabetic, who presents with cellulitis of the pannus as well as tachycardia and fever.
1. Cellulitis, which is possibly methicillin-resistant Staph aureus, given the patient’s history of skin abscesses. There are no exudates to culture. Therefore, we will continue empiric therapy with vancomycin and Zosyn IV. We will monitor spread of the erythematous area, as well as the patient’s vitals.
2. Sepsis. The patient presents with an elevated temperature to 39.6 and tachycardic with heart rate of 130. The patient was on IV vancomycin and Zosyn. We will give Tylenol and/or ibuprofen for fever. We will hold labetalol for tachycardia out of concern for sepsis and low blood pressure.
3. Diabetes. We will treat the patient with a regular insulin sliding scale as inpatient.
4. Code status. The patient is full code.
