DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Antibiotic management of postsurgical abscess.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who underwent an intramuscular lipoma resection on the back of her neck with Dr. John Doe of neurosurgery. She was doing well postoperatively until five days ago when she woke up with intense pain and decreased range of motion of her neck. She denies any fevers, chills or rigors at this time; however, she does note that her son reported that the wound site was swollen and indurated.
The patient was seen by the neurosurgery service, who obtained a superficial culture of the dehisced incision site and she was taken to the OR by Dr. Jane Doe for incision and drainage. She evacuated pus in the intramuscular layers of the neck and obtained deep cultures as well. Following the incision and drainage, she has been started on vancomycin and cefepime.
PAST MEDICAL AND SURGICAL HISTORY: Pertinent for nephrolithiasis requiring stent placement; asthma, does not require treatment; history of easy bruising. The patient is status post laparoscopic hysterectomy and laparoscopic endometrial repair.
CURRENT MEDICATIONS: Percocet, vancomycin, cefepime, albuterol, Zofran, and senna.
ALLERGIES: Sulfa drugs and macrolide antibiotics.
FAMILY HISTORY: Positive for breast cancer in her sister.
SOCIAL HISTORY: The patient is married. She lives at home with her husband and her one son. She has never used recreational drugs. Currently smokes a few cigarettes a day but in the past has smoked up to 20 for a 10-20 pack-year history, and she is a social drinker.
REVIEW OF SYSTEMS: A 10-point review of systems was performed, and it is pertinent only for that she also states that she did have limited range of motion since the initial neck surgery by Dr. John Doe and a mild decrease in appetite. Otherwise, all reviewed systems were negative.
PHYSICAL EXAMINATION:
GENERAL: The patient is a female appearing her stated age, in no acute distress, in a soft collar.
VITAL SIGNS: Blood pressure is 120/80, heart rate 64, respiratory rate 18, temperature 36.6 degrees, and she is satting at 97% on room air.
HEENT: Reveals no ocular petechial hemorrhages, benign-appearing oropharynx without any lesions or petechiae.
NECK: Reveals mild cervical lymphadenopathy and decreased range of motion due to discomfort. Postsurgical drainage site is midline on her neck. Bandage is oozing some faint serous fluid and is mildly tender to touch.
LUNGS: Clear to auscultation bilaterally.
HEART: Reveals regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Reveals good bowel sounds in all four quadrants, nontender, nondistended. She has no hepatosplenomegaly.
EXTREMITIES: Reveals no significant edema, good distal pulses, no evidence of any skin breakdown on her feet.
NEUROLOGIC: She has a symmetric neurologic examination of her upper extremities and of her face, essentially nonfocal. She is awake, alert, and interactive.
CURRENT LABORATORY DATA: Sodium 140, potassium 4.0, chloride 109, bicarbonate 24, glucose 80, BUN 10, creatinine 0.8, calcium 9.8. White blood cell count is 11.5, hemoglobin 13.8, hematocrit 43.2, and platelet count 252,000. Sed rate 24. Initial culture and deep cultures obtained during incision and drainage are all growing Staph. aureus.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old woman with a postsurgical Staphylococcus aureus abscess over posterior neck, incision successfully drained. She is doing quite well since the drainage. Given that culture results are growing Staphylococcus aureus at this time, we can continue the IV vancomycin for now pending sensitivities of the culture results but feel it is okay at this point to discontinue the cefepime.
We will plan for an oral antibiotic regimen to be determined once we have the sensitivities of the Staph. aureus result to transition her over to at the time of discharge. Given that we should have the sensitivities back in a day or so, we do not need to continue checking levels on vancomycin.
