DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Sepsis syndrome.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male known to us from his last admission last month, now readmitted with decreased level of consciousness, suspected secondary to sepsis. The history is unobtainable from the patient and is mainly obtained from the chart. The patient was started on vancomycin, ciprofloxacin, and Azactam. The urinalysis revealed pyuria and hematuria.
PAST MEDICAL HISTORY: Significant for recent admission for sepsis, encephalopathy with renal failure secondary to rhabdomyolysis, history of diabetes, hypertension, peripheral neuropathy, pneumonia, chronic renal insufficiency, hypothyroidism, and hyperlipidemia.
PAST SURGICAL HISTORY: Questionable history of cholecystectomy.
ALLERGIES: PENICILLIN.
MEDICATIONS: The patient received one dose of vancomycin and is currently on ciprofloxacin and Azactam. The patient is also on Protonix, Lovenox, and Novolin.
SOCIAL HISTORY: Unobtainable.
FAMILY HISTORY: Unobtainable.
REVIEW OF SYSTEMS: Unobtainable, as per HPI, otherwise, negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.4, pulse 86, respirations 14, blood pressure 160/62.
HEENT: Head, ears, eyes, nose, and throat unremarkable.
NECK: No lymphadenopathy.
LUNGS: Clear to auscultation.
HEART: S1 and S2, regular rhythm. The patient has a grade 2/6 murmur at the apex.
ABDOMEN: Slightly distended, nontender. Bowel sounds are present. No rebound, guarding, or rigidity.
EXTREMITIES: No edema, clubbing, or cyanosis.
NEUROLOGIC: Lethargic, but does open his eyes and does move extremities.
LABORATORY DATA: White count 20.4, hemoglobin 9.8, platelets 298,000. INR 1.34, total bilirubin 1.6, alk phos 274, ALT 146, AST 186, ammonia 38, CPK 101. Urinalysis greater than 50 rbc’s and wbc’s. Culture is pending.
IMPRESSION:
1. Sepsis syndrome causing encephalopathy secondary to urosepsis, rule out stone and hydronephrosis as he has an elevated creatinine.
2. Rule out cholangitis versus sepsis causing elevated liver enzymes. Not sure if he has a history of cholecystectomy, but ultrasound done on last admission did not visualize the gallbladder.
3. History of diabetes.
4. History of hypertension.
5. Obesity.
RECOMMENDATIONS:
1. Agree with empiric vancomycin, ciprofloxacin, and Azactam, pending cultures.
2. We would get ultrasound of biliary tree and kidneys.
3. Repeat CBC, CMP and check amylase and lipase.
4. May need a CT of abdomen.
Thank you for this consultation. Appreciate the opportunity to participate in the care of this patient. If you have any questions, please do not hesitate to contact us.
