Demographic Data: J, 53 y/o, Male

Subjective

Chief Complaint: “Came in for a follow-up.”

HPI: 53 y/o male who came to the clinic for a follow-up and an assessment of his health status. He had been evaluated in room 2. He was alert and oriented ×3. His mood was neutral, and he was cooperative during the assessment. He denies having a cough, fever, chills, night sweats, dyspnea, or SOB. Currently, the patient is not tolerating oral intake and is using total parenteral nutrition (TPN) as his main source of nutrients. He has regular bowel movements. He is continent of urine and stool. He is non-ambulatory and uses a wheelchair for mobility. Denies having memory loss. States that he sleeps throughout the night without the need for a sleep aid. He denies having a wound. Denies being on home health or hospice care. The patient’s status of advance care directive is “deferred.”

Past Medical History:

• Past Medical History: Hernia 2014 and carpal tunnel 2015.
• Surgeries and Hospitalization
• Arm debridement (2018)
• Carpal tunnel release (2015)
• Hernia repair (2014)
• Orthopedic surgery (1986)
• Medications:
• Currently on Ceftriaxone 2g until 10/6/2023
• Currently on Total Parenteral Nutrition (TPN)
• Allergies: Bee sting kit
• Health Maintenance: Due for a reassessment of septic arthritis status after he finishes his antibiotic treatment on 10/6/2023

Family History: No relevant family history provided.

Social History: No known history of tobacco or alcohol use.

Review of Symptoms

General: Patient is alert

Psychiatric: Patient is oriented

Neurology/Musculoskeletal: Non-ambulatory. Uses a wheelchair for mobility.

Cardiovascular: Denies chest pain or heart-related issues.

Pulmonary: Denies experiencing increased work of breathing

Gastrointestinal: States that he is relying on total parenteral nutrition for nutrients.

Genitourinary: States that he is continent of urine and stool

Lower Extremities: Denies noticing any swelling of his legs. States that he was diagnosed with bilateral septic arthritis and has been on antibiotic treatment.

Objective

General: no acute distress, alert

Psychiatric: appropriate affect, appropriate behavior

Neurology/Musculoskeletal: CN grossly intact

Cardiovascular: Regular rate and rhythm, no jugular venous distension, pedal pulses present

Pulmonary: no increased work of breathing, no accessory muscle use

Gastrointestinal: abdomen non-tender and non-distended, nil per oral.

Genitourinary: continent of urine and stool

Lower Extremities: non-edematous, no calf tenderness, bilateral septic arthritis

Integumentary: no rash or lesion

Assessment

Final Diagnoses

• M00.80 Arthritis due to other bacteria, unspecified joint
• R05.9 Cough, unspecified
• K59.00 Constipation, unspecified
• R25.2 Cramp and spasm

Dx Plan

Diagnostics: CBC and Arthrocentesis for assessing the status of bacterial infection.

Pharmacological: Continued antibiotic therapy for bilateral arthritis (Ceftriaxone 2g until 10/6/2023)

Non-pharmacological: Continued use of TPN for nutrition support

Education:

• Bilateral Septic Arthritis: Educate the patient on the importance of coming for arthritis follow-up weekly to assess the status of his musculoskeletal health. Educate the patient on the need to come to the clinic whenever he feels any pain, discomfort, or any other worrying signs on his lower extremities. This education is important because septic arthritis has high morbidity and mortality rates, and overlooking the need for a clinic visit could contribute to the development of serious complications (Long, Koyfman, and Gottlieb 331-332).

Follow Up:

• Follow-up date for assessment of the status of bilateral septic arthritis
• Go to the ER if symptoms persist even after taking prescribed treatment. Patients with comorbid conditions have a higher likelihood of experiencing pain or discomfort.

Health Maintenance:

• Review of patient health status on 10/11/2023, five days after he completes his antibiotic treatment for bilateral septic arthritis.

National Standards of Care/National Guidelines

National standards or septic arthritis care entail the use of antibiotic therapy to manage the bacterial infection and reduce the risks of complications of the spread of the infection to other joints  (Long, Koyfman and Gottlieb 331-332). Follow-ups are important in assessing the patient’s progress during care and determining the need to change the first antibiotic therapy in cases of drug intolerance.

Work Cited

Long, Brit, Alex Koyfman and Michael Gottlieb. “Evaluation and management of septic arthritis and its mimics in the emergency department.” Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health (2019): vol. 20, no. 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6404712/.