DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Fever, chills, rule out endocarditis.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old African-American male who has a known history of diabetes mellitus, being managed with diet only, according to the patient. He denies any complaint of exertional chest pain, denies any shortness of breath. No PND. No orthopnea. No pedal edema. The patient was here about a couple of weeks ago. He twisted his knee and then it gradually got swollen and became red. He could not take the pain; therefore, he came to the emergency department. The patient was seen and evaluated and admitted to the hospital. The patient does give a history of fever and chills and a temperature of 101.4 degrees. He denies any other complaint. The patient is lying in bed, not in any distress at the present time. The patient does have history of sleep apnea. The patient denies any previous cardiac workup in the past.
PAST MEDICAL HISTORY: Significant for diabetes mellitus, managed on diet. Previous history of hyperlipidemia, being managed on diet and under good control according to the patient. History of alcohol abuse years ago.
SOCIAL HISTORY: The patient is divorced. He is physically very active. He has three children. No history of smoking. History of alcohol use daily, mostly wine.
FAMILY HISTORY: Negative for premature coronary artery disease.
REVIEW OF SYSTEMS: Recent history of fever or chills from the past few days. No history of COPD or asthma. No history of constipation, diarrhea or rectal bleeding. No history of hemorrhoid. No history of arthritis. No history of TIA or stroke. No history of seizure disorder. Other review of systems negative.
PHYSICAL EXAMINATION:
GENERAL: Well-built muscular African-American male, lying comfortably in bed, not in any distress.
VITAL SIGNS: Blood pressure is 130/68, pulse is 76, and respirations 18.
HEENT: Head: Atraumatic and normocephalic. Eyes: Pupils are equal, round, and reactive to light and accommodation. Extraocular muscles are intact. Conjunctivae are pink. Sclerae are nonicteric. ENT: No inflammation. No discharge. Oral cavity has fair hygiene. Mucous membranes are moist and intact. No inflammation.
NECK: Supple. No JVD. No bruit. No thyromegaly.
CHEST: Clear.
HEART: S1, S2 regular. Soft systolic murmur noted.
ABDOMEN: Soft and benign. Positive bowel sounds. No organomegaly. No rebound. No guarding.
EXTREMITIES: Normal pulses. Right knee is swollen, very tender to touch with erythema and rash traveling down to the ankle. He has 1+ edema of the right leg noted.
NEUROLOGIC: Alert and oriented x 3. No gross focal deficit.
SKIN: Facial skin is warm, moist, and intact. No rashes. Skin redness noted on the right knee and traveling down to the ankle.
LABORATORY DATA: WBC 9.6, hemoglobin is 13.4, and hematocrit 38.6, platelets are 282,000. Sodium is 134, potassium is 4.2, BUN 20, and creatinine 1.1. Hemoglobin A1c is 4.9.
IMPRESSION:
1. Fever and chills, right knee sepsis.
2. Diabetes mellitus.
3. History of hyperlipidemia.
RECOMMENDATIONS: We will recommend a 2D echocardiogram to evaluate LV function and rule out any valvular lesion. Blood cultures x3 at least 1 hour apart from different locations. Start empiric antibiotics, ID consult, and orthopedic consult. In our opinion, the patient does not need any stress test at the present time. If the patient’s blood cultures are positive and the patient continues to have fever or chills, then we will recommend transesophageal echocardiogram to rule out endocarditis. Further plan of care will be dictated by the patient’s response to the above-mentioned treatment.
