Assignment: please explain rationale with source for 2 highlighted medication for the pain with cellulitis

Assignment: please explain rationale with source for 2 highlighted medication for the pain with cellulitis

Assignment: please explain rationale with source for 2 highlighted medication for the pain with cellulitis

History and Physical Note Template

Chief Complaint or Reason for Consult: “I fell and now my right lower leg has wound which is draining fluid.”

History of Present Illness (HPI):

D.G.is a 72-year-old Caucasian female with a past medical history of DM, HTN, neuropathy who presents to the ED s/ fall 10 weeks ago with a right lower leg injury described as a “rug burn”. Patient stated that she had to get up during the night to use the bathroom and she fell over an ottoman. She reports 3 weeks after the fall she started to notice erythema and swelling to her right lower leg. She also describes feeling a “pins and needles” sensation to her affected leg. Then the morning of 11/17/2022 she noticed drainage upon waking that morning. Patient right lower leg is red and warm to tough with an anteriorabscess that is draining purulent discharge. She recently went to the PCP office with her husband for his visit and the PCP started her on PO antibiotic Keflex and a diuretic. The patient states her right lower leg has not got any better since being on the antibiotic.

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Past Medical History: Diabetes Mellitus Type 2, diagnosed at age 45 years old.

Hypertension, diagnosed at age 50 years old.

Neuropathy, diagnosed at age 50 years old.

Hypothyroidism, diagnosed at age 59 years old.

Insomnia, diagnosed at age 60 years old.

Hyperlipidemia, diagnosed at age 50 years old.

Past Surgical History: C-section

Family History:

Son: Alive, 50 y/o, Hypertension

Daughter: Alive, 56 y/o, Diabetes Mellitus Type 2

Mother: Deceased, 80 y/o, living, Diabetes Mellitus Type 2, Coronary Artery Disease, Smoker

Father: Deceased, 76 y/o, Hypertension, Colon Cancer

Paternal Grandfather: Deceased, 85 y/o,Coronary Artery Disease, Stroke

Paternal Grandmother: Deceased, 80, y/o, Hyperlipidemia

Maternal Grandmother: Deceased, 89 y/o, Hypertension, Hyperlipidemia

Maternal Grandfather: Deceased, 80 y/o, COPD, smoker

Social History:D.G.is a retired sales manager who currently lives with her husband in a home in Glendale, AZ. She has two children a son and a daughter who live here as well. D.G. denies any tobacco use and illicit drug use. She admits to drinking 2-3 glasses of wine during the week. She reports getting 7 hours of sleep per day. She denies having an advanced directive in place.

Allergies: No food or drug allergies.

Home Medications: Losartan-hydrochlorothiazide– 100-25 mg by mouth daily

Janumet 50-100 mg by mouth twice daily

Levothyroxine 50 mcg by mouth daily

Multivitamin with minerals 1 tab by mouth daily

Vitamin D3 1000 units by mouth daily

Rosuvastatin -40 mg by mouth in the evening

Melatonin 6 mg by mouth at bedtime

Pregabalin 75 mg by mouth twice daily

Hospital Medications:

• Acetaminophen 650 mg, oral Q6H PRN
• Acetaminophen suppository 650 mg Rectal Q6H, PRN
• Glucose chewable tablet 16 g, oral Q15min PRN or Dextrose 50% syringe 50mL, 25 g, Intravenous Q 15 min PRN
• Colace 200 mg oral HS PRN
• Senokot tablet 17.2 mg, 2 tablets oral HS PRN
• Lovenox injection 40 mg, SUBQ at HS
• Insulin Humalog injection 1-25 units, SUBQ QID, CC+HS
• Levothyroxine 50 mcg oral in AM
• Losartan 100 mg or Q24H
• Melatonin 6 mg, oral, Q24H at HS
• Oxy IR 5 mg, oral Q4H PRN
• Morphine 4mg/mL injection, Intravenous, Q4H PRN
• Narcan 0.4 mg/mL injection, Intravenous, Q2MIN, PRN
• Zofran 4mg, Intravenous, Q6H PRN
• Zosyn 3.375 g, Intravenous, Q8H scheduled
• Vancomycin 1000 mg, Intravenous, Q8H
• Lyrica 75 mg, oral, BID

Review of Systems:

• CONSTITUTIONAL: Positive energy levels. Denies fever/chills or significant weight changes.
• EYES: Denies vision changes, eye pain, or double vision.
• EARS, NOSE, and THROAT: Denies hearing loss, tinnitus, ear discharge, facial pain, sneezing, rhinorrhea, throat pain, hoarse voice, sore tongue, or bleeding gums.
• CARDIOVASCULAR: Negative for SOB, chest pain, palpitations. Positive for BLE edema.
• RESPIRATORY: Negative for SOB, cough, chest tightness, sputum production, and wheezing.
• GASTROINTESTINAL: Denies epigastric/abdominal pain, flatulence, bloating, diarrhea, constipation, or tarry stools.
• GENITOURINARY: Denies dysuria, penile discharge, increased urination, or urinary urgency or frequency.
• MUSCULOSKELETAL: Denies joint pain, stiffness, muscle cramps. Positive for BLE edema. Limited ROM to RLE.
• INTEGUMENTARY: Denies bruises. Positive for RLE erythema. Positive for blister to anterior RLE with purulent drainage.
• NEUROLOGICAL: Negative for dizziness, headache, fainting, muscle weakness. Positive for pins and needles sensation.
• PSYCHIATRIC: Denies having anxiety or depressive symptoms.
• ENDOCRINE: Denies heat/cold intolerance, acute thirst, or hunger.
• HEMATOLOGIC/LYMPHATIC: Denies bleeding, bruising, or lymph node enlargement.
• ALLERGIC/IMMUNOLOGIC: Negative for hives or allergies.

Physical Exam:

• GENERAL APPEARANCE: The patient is a 72-year-old female. She is calm, alert, oriented x 4, and in no distress. She maintains eye contact and has clear and coherent speech.
• VITAL SIGNS: BP- 156/86; HR- 99; RR-20; Temp: 98.4; Sp02-97 RA; Wt-250; Ht-5’6; BMI- 40.3
• HEENT: Head: Normocephalic and symmetrical. Eyes: Sclera is white and conjunctiva pink; No excessive lacrimation; PERRLA. Ears: Tympanic membranes are shiny and intact. Nose: No nasal secretions or bleeding; The nasal septum is well-aligned. Mouth & Throat: Pink and moist mucous membranes; Tonsillar glands are non-erythematous.
• NECK: Full neck ROM. The trachea is midline and well-aligned.
• CHEST: Nontender to palpation.
• LUNGS: Breath sounds are equal and clear bilaterally. No wheezes, rhonchi, or rales.
• HEART: Regular rate and rhythm with normal S1 and S2. No murmurs, gallops, or rubs.
• BREASTS: No nipple discharge, breast tenderness, or mass.
• ABDOMEN: Abdomen is rounded, soft with no distension or scars; Normoactive BS in all quadrants. No epigastric or abdominal tenderness or organomegaly.
• GENITOURINARY: No avialian or discharge.
• RECTAL: Normal sphincter tone. No masses or tenderness.
• EXTREMITIES: Full ROM in upper in upper extremities. Limited ROM and lower limbs. No joint stiffness or enlargement.
• NEUROLOGIC: Normal gait and posture. Muscle strength 4/5 to RLE, all other extremities 5/5.
• PSYCHIATRIC: No anxiety or depressive symptoms noted. Logical and goal-directed thought content and process.
• SKIN: Warm and dry. RLE shiny, warm to touch, erythema noted and anterior abscess
• LYMPHATICS: Lymph nodes are non-palpable.

Laboratory and Radiology Results:

11/17/22

CBC

WBC                                                   5.8

RBC                                                    3.54

Hgb                                                     10.8

HCT                                                    32.5

MCV                                                   91.8

MCH                                                   30.5

MCHC                                                            33.2

RDW-SD                                            45.7

RDW-CV                                            13.3

Platelets                                               254

MVP                                                   10.2

Lymphs                                               14

Lymphocytes Absolute                       0.80

Monocytes                                          12

Monocyte Absolute                            0.67

Eosinophils                                          2

Eosinophils Absolute                          0.10

Basophils                                             0

Basophils Absolute                             <0.05

Neutrophils                                         72

Neutrophils Absolute                          4.19

Immature Grans                                  1

Immature Grans Absolute                   0.05

Nucleated RBC Absolute                   0.000

nRBC                                                  <1.0

PT                                                        13.0

INR                                                     0.97

CMP

Glucose                                               133

BUN                                                   55

Creatinine                                            0.9

eGFR                                                  >60

Sodium                                                136

Potassium                                            4.0

Chloride                                              105

CO2                                                    27

Anion Gap                                          4

Blood Cultures x 2   

• 1^st setà No growth at 48 hours.
• 2^nd setà No growth at 48 hours.

X-Ray TibFib 2 Viewsà                  No fracture or dislocation

US Duplex Venous RT Legà          No evidence of deep venous thrombus involving right common femoral, superficial femoral, and popliteal veins.

Culture Aerobic Wound RT LegàScant growth staphylococcus aureus

Differential Diagnosis:

Cellulitis: This is a non-necrotizing inflammation of the skin and subcutaneous tissue caused by a primary infection. The four typical symptoms are pain, swelling, warmth, and erythema. In moderate to severe infection, patients present with fever, malaise, chills, altered mental status, tachypnea, tachycardia, hypotension, and toxicity (Sullivan & de Barra, 2018). Cellulitis is a differential diagnosis based on positive findings of erythema and swelling in the right lower leg. Purulent cellulitis presents with pus in the affected part (Sullivan & de Barra, 2018). Similarly, the patient’s right lower leg is red and warm to touch and has an anterior abscess draining purulent discharge. Physical exam findings of the right leg that is shiny, warm to touch, erythematous, and anterior abscess indicate Cellulitis.

Thrombophlebitis: This is characterized by the formation of a blood clot due to venous inflammation or injury. A thrombus develops in a vein located close to the skin surface. It presents with a gradual onset of localized tenderness on the affected limb, followed by an area of erythema along the direction of a superficial vein (Stevens et al., 2019). Physical findings include a hot, swollen leg. Thrombophlebitis is a differential diagnosis based on positive findings of edema, erythema, and tenderness on the right lower leg. This diagnosis was ruled out due to negative ultrasound.

DVT: DVT occurs due to blood clotting in the deep vein of a limb or the pelvis. Clinical features include tenderness, edema, leg pain, warmth, and erythema of the skin over the thrombosis area. Physical findings include calf tenderness, swelling of the whole leg, a difference in circumference between calves >3 cm, pitting edema, and collateral superficial vein (Kruger et al., 2019). The findings of right lower leg edema, tenderness, erythema, and warmth make DVT a likely diagnosis. This diagnosis was ruled out due to negative ultrasound.

Working Diagnosis: Cellulitis of right lower leg with abscess

Problem List

• Acute and Chronic Medical Conditions:

 

1. Cellulitis of right lower leg with abscess 115
2. Diabetes Mellitus Type 2                         9
3. Essential Hypertension                         I10
4. Hyperlipidemia                         5
5. Hypothyroidism                                     9
6. Neuropathy                          9
7. Obesity                         9
8. Insomnia                          00

Treatment Plan:        

• Blood cultures x 2 no growth
• Wound culture RLE
• Start IV antibiotics: Zosyn 3.375 g intravenously every 8^o and Vacomycin15mg/kg intravenously every 12^o. The patient has purulent cellulitis, which is regarded as high risk and its treatment should include coverage for methicillin-resistant staphylococcus aureus (MRSA) (Sullivan & de Barra, 2018).
• Transition to PO antibiotics at dischargeBactrim DS by mouth twice daily x 7 days and Augmentin by mouth twice daily x 7 days (Epocrates, 2022).
• Consult Infectious disease
• Consult podiatry for RLE abscess
• Elevation of extremity to help prevent edema
• Moist heat for pain relief
• Tylenol 1000 mg PO for pain relief every 6o scheduled, (moderate pain 4-6): Tylenol will be administered to alleviate pain associated with the inflammatory process in cellulitis (Rangel et al., 2022). It acts peripherally to block pain impulse generation and inhibit prostaglandin synthesis in CNS, thus suppressing pain.
• Oxy IR 5mg PO for pain Q4o pain, (severe pain 7-10): Oxy IR is indicated in moderate-to-severe pain. It is a narcotic agonist-analgesic of opiate receptors and acts by inhibiting ascending pain pathways. This alters pain response producing analgesia. Oxy IR will be used to relieve pain caused by the inflammatory process in cellulitis and alleviate inflammatory symptoms (Rangel et al., 2022).
• Hold home diabetic meds
• Start SSI
• Resume home med losartan daily
• Resume home med rosuvastatin
• Resume home med levothyroxine
• Resume lyrica PO BID
• Educate on health BMI and diabetic diet
• Educate in engaging in 20-30 min at least 3 x a week
• Resume home med melatonin

Health Education:

The patient will be advised to maintain cleanliness of the affected right lower leg to avoid secondary infection. She will also be advised to adhere to the antibiotic therapy to promote full recovery and avoid re-infection(Sullivan & de Barra, 2018). Besides, she will be advised to seek medical attention in case the symptoms worsen.

Consultations: Podiatryàwound debridement

Infectious Diseaseàright lower extremity abscess

Follow-up: A follow-up will be scheduled in the outpatient clinic after one week to monitor response to treatment and assess complications.

Follow-up will be with infectious disease, podiatry and internal medicine.

Geriatric or Ethical Considerations:

Kumar et al. (2019) explain that age alone does not change treatment principles for bacterial cellulitis, including antibiotic therapy. Nonetheless, age-related pharmacokinetics and pharmacodynamics, social circumstances, and cognitive status in elderly patients, especially those above 75, may influence treatment decisions, mostly the need for hospitalization. Therefore, the patient’s age will not lead to changes in antibiotic therapy. However, hospitalization would be considered if she is at risk of falls. Legal considerations for this case surround beneficence and nonmaleficence. The clinician should uphold the two principles by implementing treatment interventions associated with the best outcomes and least or no harm to patients.

References

Epocrates mobile app (2022).

Kruger, P. C., Eikelboom, J. W., Douketis, J. D., & Hankey, G. J. (2019). Deep vein thrombosis: update on diagnosis and management. The Medical journal of Australia, 210(11), 516–524. https://doi.org/10.5694/mja2.50201

Kumar, M., Jong Ngian, V. J., Yeong, C., Keighley, C., Van Nguyen, H., & Ong, B. S. (2019). Cellulitis in older people over 75 years – are there differences?. Annals of medicine and surgery (2012), 49, 37–40. https://doi.org/10.1016/j.amsu.2019.11.012

Rangel, T., Pham, S., Senger, B., Daratha, K., Fitzgerald, C., Mallo, R., & Daratha, K. (2022). Pharmacologic Pain Management Trends among Adults Hospitalized with Cellulitis: An Evidence-Based Practice Project. Pain management nursing : official journal of the American Society of Pain Management Nurses, S1524-9042(22)00182-5. Advance online publication. https://doi.org/10.1016/j.pmn.2022.09.003

Stevens, H., Tran, H., & Gibbs, H. (2019). Venous thromboembolism: current management. Australian prescriber, 42(4), 123–126. https://doi.org/10.18773/austprescr.2019.039

Sullivan, T., & de Barra, E. (2018). Diagnosis and management of cellulitis. Clinical medicine (London, England), 18(2), 160–163. https://doi.org/10.7861/clinmedicine.18-2-160