DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Right total knee arthroplasty infection.
HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic male with osteoarthritis and prediabetes had a right total knee arthroplasty. He had an uneventful postoperative course until approximately four days prior to admission, when he developed pain and swelling of his right knee. He reports that prior to that, he was exercising with a weight machine and accidentally hit his right knee with one of the machines. Because of progressive pain and swelling, the patient went to the emergency room where he had an aspirate performed that repeatedly showed significantly elevated white blood count in the joint fluid.
The patient was admitted with an admission white count of 16,400, 93% segs, normal bands. Sedimentation rate was 64, creatinine was 1.2, CRP was 320. Blood cultures x2 were sent, which today are growing out gram-positive cocci. After surgery, the patient had been started empirically on vancomycin 1 gram IV q.12 and cefepime 1 gram IV q.12. The right knee culture is negative to date. The Gram stain, however, showed 1+ wbc’s and 1+ gram-positive cocci. The patient has been febrile overnight to 102.4. He is currently complaining of knee pain. Denies history of skin or soft tissue infection at other sites. Postoperatively, the patient developed atrial fibrillation with rapid ventricular response. The patient says this is of new onset. He has a transthoracic echocardiogram ordered.
ALLERGIES: NKDA
MEDICATIONS: Acetaminophen, albuterol inhaler p.r.n., aspirin 325 mg p.o. daily, Celebrex, diltiazem, Benadryl, ferrous gluconate, hydrochlorothiazide, hydralazine p.r.n., insulin sliding scale, meperidine p.r.n., morphine p.r.n., multivitamin, ondansetron p.r.n., oxycodone p.r.n., senna p.r.n., and promethazine p.r.n.
SIGNIFICANT MEDICAL ILLNESSES: As above. Denies liver disease, kidney disease, heart disease, cancer or tumor.
PAST SURGICAL HISTORY: As above.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient is married and lives with his wife. He is a nonsmoker, nondrinker. No IV or recreational drugs.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As above. He says he may have had some chills prior to admission but does not recall having any fevers. No weight loss.
HEENT: No recent dental work. No chronic sinus or ear infections.
PULMONARY: No chronic lung infections.
CARDIOVASCULAR: No PND, orthopnea, or dyspnea on exertion.
GASTROINTESTINAL: No nausea, vomiting, diarrhea, abdominal pain.
GENITOURINARY: No chronic urinary tract infections.
MUSCULOSKELETAL: As above.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: Well-developed, obese, Hispanic male, looks his stated age, in no acute distress.
VITAL SIGNS: T-max is 102.4, currently low grade. Vital signs are stable.
SKIN: No splinter hemorrhages, Janeway lesions or Osler’s node. No petechiae.
HEENT: Normocephalic, atraumatic. No conjunctival pallor or petechiae.
NECK: Supple.
LUNGS: Clear.
HEART: Irregularly irregular without murmurs, rubs or gallops.
ABDOMEN: Protuberant, normal bowel sounds, soft, nontender, without hepatosplenomegaly or masses.
EXTREMITIES: Right leg: Dressing is intact. There is a small amount of bloody drainage visible on the dressing lateral and inferior to the right knee. Otherwise, dressing is intact. He now moves his right toes without difficulty. He has a JP drain in place with a small amount of bloody drainage.
DIAGNOSTIC DATA: White blood count of 11,000, 89% segs. Platelet count of 134,000.
ASSESSMENT:
1. Gram-positive cocci bacteremia.
2. Right total knee arthroplasty infection.
3. Status post incision and drainage of right total knee arthroplasty infection.
4. Right total knee arthroplasty for osteoarthritis.
5. Obesity.
6. History of elevated blood sugars.
7. History of kidney stones.
8. New onset atrial fibrillation.
DISCUSSION: This patient, who is status post right total knee arthroplasty for osteoarthritis, had closed trauma to his right knee with subsequent pain and swelling. He is bacteremic and has gram-positive cocci on the Gram stains from his right knee culture. Suspect this is most likely Staph. Could be either Staph aureus or coag-negative Staph. Less likely enterococci or other Strep. Despite his continued fevers and his atrial fib, he is hemodynamically stable and does not appear toxic.
RECOMMENDATIONS:
1. Follow up cultures.
2. Repeat blood cultures x2 in a.m.
3. Discontinue vancomycin and cefepime.
4. Change to daptomycin 6 mg/kg IV q.24 hours.
5. Follow up transthoracic echocardiogram.
6. If the echo above is nondiagnostic, would consider TEE to exclude endocarditis.
7. Followup CBC.
8. Check CK once a week while on daptomycin.
Thank you very much for this consult. We will follow the patient with you.
