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Original Question

The following documentation is from the health record of a 34-year-old male patient. Admission Diagnosis: Sickle cell pain crisis. Discharge Diagnosis: Sickle cell pain crisis/Staph (Staphylococcus) aureus bacteremia. Secondary Diagnosis: Sickle cell disease, priapism, chronic lower back pain secondary to sickle cell diagnosis, mild persistent asthma, gastroesophageal reflux disease (GERD), and grade 2 hemorrhoids. Consults: None. Procedures: PICC line placement, and transesophageal echocardiogram (heart and aorta). Hospital Course: The patient is a 34-year-old African-American male with a history of sickle cell disease who presented with back pain and whole body pain, a remote history of some diarrhea and nausea, and some fevers and chills. Blood cultures taken on admission and during his first night as an inpatient grew four out of four bottles of S. aureus. The patient received 1 gm of ceftriaxone in the emergency department and received approximately six days of vancomycin IV as an inpatient. Thereafter he was switched to Ancef 1 gm IV q.8 hours. To find a source for the patient’s Staph. bacteremia, a transesophageal echo-cardiogram was done which did not show evidence of any cardiac vegetations. Because the patient had Staph. bacteremia of unknown source, Infectious Disease was consulted. As per their recommendation, the patient is to be on five weeks of IV Ancef. At the time of admission, the patient was placed on a PCA pump. He was rapidly weaned off this and he was also placed on some oxygen and was bolused with fluids and kept on maintenance fluids. The patient’s clinical status improved rapidly. He was soon weaned off the oxygen, fluids, and pain medications. At the time of discharge, the patient is afebrile and stable. A PICC line was placed in order to ensure access for the next five weeks, during which he will receive his IV antibiotics. The PICC line was placed percutaneously into the superior vena cava. Home care and home IV teaching was arranged for the patient and his family. Follow-Up: Hematology was contacted and follow-up will be arranged within the next two weeks. Follow-up will also be arranged with Infectious Disease in five weeks. Home medications include folate 1 mg p.o. q.d.; Flexeril 10 mg p.o. b.i.d.; Ancef 2 gm q.12 IV times five weeks; Phenergan 12.5 mg p.o. q.4 p.r.n. nausea; and Zantac 150 mg p.o. b.i.d. The patient was told to return for fevers, chills, sweats, nausea, vomiting, or bone or muscle pain. Disposition is to home with home care. Code Assignment Including POA Indicator

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