DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Diverticulitis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American male with a history of diabetes who was admitted with complaints of one-week abdominal pain. The patient has been found with CT scan showing gas, fluid collection, and questionable focal abscess. He has also been complaining of stool in his urine for which he has been seen for diverticulitis with colovesical fistula and questionable abscess. The patient is currently n.p.o. and he has been scheduled for surgery. At time of my consultation, the patient denies fever, although he did complain of night sweats and chills. He states he recently had urinary tract infection treated with 10 days of antibiotics from primary care provider. He states that he has had worsening abdominal pain over the last seven days. He denies any recent trauma or other complains. He states he has noted stool in his urine for the last four to five days. He has lost approximately 50 pounds and complains of poor appetite. He denies cough. He states he has mild shortness of breath. He states no one has been sick at home recently.
PAST MEDICAL HISTORY: Diabetes.
PAST SURGICAL HISTORY: Appendectomy and laser surgery to the left eye.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He denies tobacco use. He used to drink alcohol, but he has quit. He is married and has three children.
FAMILY HISTORY: Significant for diabetes.
MEDICATIONS: Zosyn and Flagyl.
REVIEW OF SYSTEMS: Except for the systems stated above, there are no other cutaneous, lymphatic, endocrine, neurologic, musculoskeletal, cardiovascular, genitourinary, or systemic complaints.
PHYSICAL EXAMINATION: Temperature 98.6, blood pressure 84/58, respiratory rate 22, and heart rate 92. He has no generalized skin rash or lymphadenopathy. Normocephalic and atraumatic. No facial rash or external lesions of the ears or nose. Oral mucosa is pink with no exudate. No intraoral thrush or lesions. No palpable lymphadenopathy or masses. His left eye is noted with pink conjunctiva, but no purulent drainage. Lungs are clear to auscultation bilaterally. Heart is regular rate and rhythm with no auscultated murmur, rub, or gallop. Abdomen is soft. He has does have a palpable mass near the left umbilicus to the left lower quadrant that is tender to palpation. The patient states the tenderness is worse with rebound. Extremities are without cyanosis, clubbing, or edema.
LABORATORY DATA: WBC is 7.8, H&H 11.4 and 34.4, and platelets 302,000. Creatinine 0.7. Lipase is 18 and amylase is 32. Urinalysis taken yesterday shows no leukocyte esterase, no nitrites, no wbc, or bacteria. Repeat UA shows 2+ leukocyte esterase, no nitrites, 4+ bacteria, and greater than 50 wbc’s. Urine culture is currently pending.
DIAGNOSTIC STUDIES: Abdominal and pelvic CT shows left lower quadrant inflammatory changes with the 4.5 x 7.5 cm gas and fluid collection in the left lower quadrant, question focal abscess versus unopacified loop of the bowel.
ASSESSMENT AND PLAN: This (XX)-year-old male with history of diabetes has been found with possible abdominal abscess with likely colonic bladder fistula. At this time, we will place him on broad-spectrum antibiotics and provide anaerobic coverage, agree with use of Zosyn. We would like to increase his dose, however, to 4.5 g IV q. 6 h. and will await surgical intervention. The above was discussed with the patient.
Thank you very much, Dr. Doe, for this infectious disease consultation.
