DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Leukocytosis.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old African-American female admitted with abdominal pain. The patient was recently treated with Cipro for E. coli urinary tract infection. She has been constipated for about a week. The patient denies any nausea or vomiting. No cough, no significant fevers or chills. She had a CT of the abdomen on admission, which reveals the findings were consistent with diverticulitis. The patient was started on Rocephin and Flagyl. Her white count has increased today to 21,000. In general, the patient does feel a little better today.
PAST MEDICAL HISTORY: Significant for diverticulitis and diabetes.
PAST SURGICAL HISTORY: Cataract surgery.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient is currently on Rocephin IV and oral Flagyl.
SOCIAL HISTORY: She denies tobacco or alcohol abuse.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As per history of present illness, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.4, pulse 86, respirations 18, blood pressure 124/54.
HEENT: Unremarkable.
NECK: No lymphadenopathy.
LUNGS: Clear to auscultation.
HEART: S1, S2, regular rhythm. The patient has a grade 2 to 3/6 systolic murmur at the apex.
ABDOMEN: The patient has lower abdominal tenderness, mostly in the suprapubic and right lower quadrant. No rebound, guarding, or rigidity. Bowel sounds are present.
EXTREMITIES: No edema, clubbing, or cyanosis.
NEUROLOGIC: No focal neurological deficits.
LABORATORY DATA: White count 20.8, hemoglobin 10.2, platelets 240, BUN and creatinine 24 and 1.7. Urinalysis with 5-10 wbc’s and 0-4 rbc’s with 2+ leukocyte esterase.
DIAGNOSTIC DATA: CT of the abdomen as mentioned, inflammatory changes around the diverticula. MRI of the abdomen with no significant pathology. Ultrasound of the gallbladder within normal limits.
IMPRESSION:
1. Leukocytosis, rule out diverticular abscess as initial CT scan was consistent with diverticulitis.
2. Renal insufficiency.
3. History of Escherichia coli urinary tract infection, rule out persistent infection, persistent urinary tract infection.
4. Heart murmur.
RECOMMENDATIONS:
1. Continue present antibiotics.
2. Repeat urinalysis and culture.
3. We would get stool, WBC, and occult blood.
4. X-ray of the abdomen.
Thank you, Dr. Doe, for referring this pleasant patient to us.
