CONSULTATION REPORT

REASON FOR CONSULTATION:  This patient is being seen at the request of Dr. Daffy Duck for chronic osteomyelitis of the right proximal tibia. 

HISTORY OF PRESENT ILLNESS:  The patient is known to us.  March 20 he fell as he was beginning to ascend a ladder and sustained a fracture of the right proximal humerus and the right tibial plateau.  He underwent open reduction internal fixation of the proximal humerus where there was reportedly hematoma and rotator cuff tear, and closed reduction and internal fixation with Liss plate of the right tibial plateau fracture and subsequent closed reduction and internal fixation of the tibial tuberosity fracture.  The fixing pins were reportedly removed from the right humerus approximately a month later, when healing of the bone had been demonstrated.  He subsequently developed drainage from a right shoulder sinus tract, with surface cultures growing methicillin-resistant Staphylococcus aureus (MRSA).  He apparently took oral antibiotics for several months, without improvement.  In 10/01, he was readmitted here, where he underwent a debridement of the right proximal humerus by Dr. Elmer Fudd.  Deep cultures confirmed the presence of methicillin-resistant Staphylococcus aureus (MRSA).  A PICC line was placed and he was treated with approximately six weeks of IV vancomycin.  He apparently was only seen one time in the office on November 14, but there is a record that the antimicrobials were stopped and the PICC line removed on December 3. 

In March of this year, he developed redness and swelling over the anterior aspect of the right proximal tibia and was readmitted here from March 23 to March 29 by Dr. Bugs Bunny undergoing explantation of the fixing hardware on March 25.  Cultures from this site also grew methicillin-resistant Staphylococcus aureus (MRSA).  A PICC line was placed and he reportedly received approximately six weeks of IV vancomycin.  I do not have records of the outpatient therapy, but we were not involved in his care and this was supervised by XYZ orthopedics. 

He was readmitted here from April 15 to April 18 with persistent drainage.  He was apparently still on vancomycin at that time and underwent further debridement.  He thinks he was off vancomycin by early to mid May.

In spite of the explantation of the hardware and debridement, he had a persistent draining sinus tract over the anterior aspect of the right proximal tibia.  On Friday, he was readmitted to the hospital after the apparent radiographic identification of a sequestrum at that site.  On that day, he underwent a sequestrectomy and was started on vancomycin 1 gram IV q.12 h. and, on this occasion, oral rifampin 300 mg p.o. b.i.d.  His cultures are now reported to again be growing methicillin-resistant Staphylococcus aureus (MRSA), but also Streptococcus viridans and an anaerobic gram-negative bacillus in both specimens submitted for culture.

He tells me that he was afebrile prior to admission and has remained afebrile since coming back to the hospital.  On admission white blood cell count was 6700, hemoglobin 13.3, hematocrit 40, and platelet count 226,000.  Creatinine 1.1, random blood sugar 239.  A trough vancomycin level obtained with the fourth vancomycin dose was therapeutic at 11. 

The past history is further remarkable for reportedly diet-controlled (although inpatient blood sugar does not suggest this) type 2 diabetes mellitus.  He has not had any complications of this problem.

ALLERGIES:  No known drug allergies. 

Current weight is 243 pounds.  

PHYSICAL EXAMINATION:  Well-developed, well-nourished, middle-aged, Caucasian male in no physical distress.  VITAL SIGNS:  See graphic record.  Afebrile.  LYMPHATICS:  No palpable adenopathy of significance at any site.  INTEGUMENT:  Complexion somewhat sallow, but otherwise unremarkable.  Nails poorly kept, with loss of the left great toenail.  Some superficial eschars present over the feet, suggesting poor foot care.  Hair distribution and hair texture normal for race, sex and age.  HEENT:  Cranial and facial contours normal.  External auditory canals patent, with normal-appearing tympanic membranes.  No tenderness over the paranasal sinuses.  Nose patent.  Lips unremarkable.  Dental hygiene poor, with caries, staining of the teeth and chronic gingival disease, but the mucosa of the oropharynx and posterior pharynx benign.  EYES:  No abnormalities of the lids, sclerae or conjunctivae noted.  Pupils equal, round, reactive to light.  Extraocular movements conjugate.  Fundi unremarkable.  No evidence of diabetic retinopathy.  NECK:  Supple.  No palpable abnormalities of the thyroid.  CHEST:  Symmetrical expansion noted and the chest was resonant throughout to percussion and clear to auscultation.  PRECORDIUM:  Apical impulse could not be localized.  No pathologic jugular venous distention.  Carotid pulses physiologic bilaterally.  No bruits noted.  First and second heart sounds normal, with physiologic splitting of S2.  No murmurs, gallops or rubs present.  ABDOMEN:  Bowel sounds normal active.  No visible surgical scars.  Nondistended.  Soft, without apparent tenderness.  No masses.  No splenomegaly, hepatomegaly or hepatic tenderness.  GU:  No CVA tenderness.  Penis circumcised, without lesions.  Testes descended bilaterally.  No scrotal masses or scrotal tenderness present.  RECTAL:  Deferred.  SPINE, EXTREMITIES:  No tenderness over the vertebral bodies.  No deformities of the spine noted.  Right shoulder revealed multiple surgical scars and a 1 mm dry eschar over the mid anterior aspect of the joint.  There was significant limitation of range of motion of the right shoulder.  Right lower extremity was in a soft cast and dressed at the knee with a Jackson-Pratt drain in place.  This bandage was not taken down at this time.  The right foot was cool but not discolored.  The lower extremity pulses could not be felt with certainty.  The left lower extremity was likewise somewhat cool, with absent pulses but without discoloration.  NEUROLOGIC:  Alert and fully lucid.  No gross focal deficits noted, although he was not examined in detail. 

PROBLEM LIST:
1.  Chronic osteomyelitis of the right proximal tibia, status post fixing hardware removal on 3/25/02, history of irrigation and debridement on 4/16/02, history of sequestrectomy on 9/6/02, methicillin-resistant Staphylococcus aureus (MRSA), Streptococcus viridans and anaerobic gram-negative rods.
2.  History of osteomyelitis of the right proximal humerus, methicillin-resistant Staphylococcus aureus (MRSA) in 10/01, pin removal 5/01.
3.   Right proximal humeral fracture with closed reduction and internal fixation and right proximal tibial fracture with closed reduction and internal fixation 4/01.
4.  Type 2 noninsulin dependent diabetes mellitus.

RECOMMENDATIONS:
1.  Agree with a prolonged course of IV and p.o. antibiotics for 6-8 weeks utilizing vancomycin 1000 mg IV q.12 h.,
rifampin 300 mg p.o. b.i.d., and metronidazole 500 mg p.o. q.i.d.
2.    Outpatient orders written.
3.  Proceed with PICC line placement as planned.

Thank you for allowing us to see this patient in consultation.  We will be happy to follow with you.