Chief Complaint: Back pain on post op day 1 status post right total hip arthroplasty. She had a history infected right native hip, status post right hip resection arthroplasty with spacer placement procedure 4 months ago (first stage), now in need of total hip arthroplasty (second stage)
Hx of infected right native hip, status post right hip resection arthroplasty with spacer placement procedure 4 months ago (first stage), now in need of total hip arthroplasty replacement (second stage).
History of Present Illness:
A 36-year-old female with end-stage renal disease from hypertension, previously had a systemic methicillin-resistant staphylococcus aureus (MRSA) infection due to an infected hemodialysis catheter. She eventually developed a right hip MRSA infection that destroyed her joint. She underwent a two-stage approach. Stage I was a resection arthroplasty with a Girdlestone procedure. This included placing an antibiotic-loaded spacer into her acetabulum and down her femoral shaft. She required treatment with organism-specific IV antibiotics for a minimum of 8 weeks. After this, she would be considered for a total hip arthroplasty 3 to 4 months after the initial procedure. If she were unable to clear her infection, she would be left with a Girdlestone, a right native hip resection with spacer placement.
She was treated postoperatively with daptomycin for approximately 8 weeks and another 8 weeks with doxycycline. She was followed up by the infectious disease consultant, her ESR and CRP was improving and she was scheduled to undergo a total hip replacement. The patient had been living in a skilled nursing facility since her 1st stage surgery. She was having pain with movements and with touchdown toe bearing on her right leg. She had been working with physical therapy and had been trying to use a walker. She had no major medical illnesses since her previous surgery. She was on hemodialysis 3 times a week, and her last dialysis was a day before surgery.
As far as the patient's chronic medical conditions, in addition to hypertension, dialysis-dependent ESRD, and the treated MSRA infection. She specifically denied a history of heart attack, coronary artery disease, congestive heart failure, stroke, easy bruising or diabetes. She tolerated her previous surgery with no cardiovascular complications. As far as her functional status, she had previously used a walker to ambulate short distances, but was wheelchair-bound.
Past Medical History:
1. End-stage renal disease from hypertension, on hemodialysis,
2. History of a systemic MRSA infection. She has been on chronic renal dialysis, most recently via a left upper extremity AV fistula. She previously had line epsis associated with the right subclavian dialysis catheter. This was believed to be a source of infection in her right hip. She was noted to develop a right septic hip that was treated 2 years ago with operative irrigation and debridement. She was treated with vancomycin for 8 weeks after this and then was noted to have a persistent infection; an aspiration confirmed the findings of infection. She had been treated with oral Zyvox, which she continues on at this time. She has had progressive hip and back pain and decreased mobility because of the right hip. Her radiographs showed severe degenerative changes and obliteration of her femoral head. She is continuing to have severe back and hip pain and her mobility is limited. She has been using a wheelchair for the past 3 months. She is requiring hydromophone (Dilaudid) injections for continued pain relief.
3. Asthma
4. Anemia
5. Hypertension
6. Chronic pain
7. Tobacco abuse
Past Surgical History:
1. Status post right hip resection 4 months ago under regional anesthesia (CSE).
2. Status post right hip irrigation and debridement 2 years ago.
3. Status post AV fistula placement.
4. Status post tubal ligation.
She denies having trouble with anesthesia, bleeding problems, or blood clots.
Medications
Nephrovite 1 tab daily
Vit B complex w/vit B12 daily
Vasotec 20 mg bid
Epogen w/HD
Clonidine 0.1mg every 8 hours
ASA EC 81 mg daily
Doxazosin 8 mg BID
Furosemide 40 mg daily
Nifedipine ER 60 mg BID
Renagel 4000 mg TID w/meals
Nepro 1 can daily
Pro-Stat 30 ml BID
Colace 200 mg BID
Doxycyline 100 mg BID - stopped 1/14/08
Klonopin 1 mg BID
Albuterol 2.5 mg HHN q6 hr PRN
Ipratropium 0.5 mg HHN q6 hr PRN
Vicodin 5/500 mg q 4 hr 2 tabs
Dilaudid 1 mg IM q6 hrs PRN breakthrough pain
Oxycodone 5 or 10 mg q 3hr for breakthrough pain
Compazine 10 mg q8hr prn n/v
Allergies: No known drug allergies.
Family History: Non-contributory
Social History: The patient is divorced. She has 7 children. She is living in a nursing facility at this time. She is to work as a caregiver but is currently not working. She smokes half a pack per day for about 1 year. She does not drink alcohol or use recreational drugs
Review of Systems: Not significant
Physical Exam: Vital Signs: Blood pressure 142/95, pulse 78 and regular, temperature 97.6, oxygen saturation 98% on room air, weight 180 pounds and height 5'7". General: The patient is in no acute distress and looks chronically ill She is alert and oriented x3. HEENT: Eyes: Pupils are equally round and reactive to light. The sclerae are anicteric. Ears, Nose, Mouth, and Throat: Oropharynx is clear. There is no nasal discharge. Neck: Supple. There is no thyromegaly. Respiratory: Lungs are clear to auscultation bilaterally. There are no retractions. Cardiovascular: regular rate and rhythm; no lower extremity edema. There is a 2/6 systolic ejection murmur heard loudest at the apex. Abdomen: Soft, nontender and nondistended. No masses or organomegaly are appreciated. The abdomen is obese. Skin: No obvious rash. Skin is smooth to palpation. Extremities: No edema. She does have a dialysis shunt in her left upper extremity. Lymph Nodes: There is no obvious cervical, supraclavicular, or infraclavicular lymphadenopathy.
Laboratory Data: White blood cell count 5.8, Hemoglobin 11.1, Hematocrit 44.2, Platelets 274, sedimentation rate is 9, PTT 26.1 and INR 1.1. Potassium 5.3, BUN 61, and creatinine 10.8. Urinalysis has greater than 300 protein, trace blood, trace reducing substance and 5 to 7 white blood cells.
Radiological Data: Right Hip X-rays: Severe degenerative changes and obliteration of her femoral head.
EKG: Normal sinus rhythm at a rate of 69. No Q waves or ischemic changes.