DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Elevated white blood cell count.
CHIEF COMPLAINT: Shortness of breath.
Thank you for this interesting consult and allowing us to participate in this patient’s care.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Asian female with a history of hypertension who presents with complaints of shortness of breath. She was seen and evaluated by the emergency department physician and subsequently admitted. The patient required care in the intensive care unit due to respiratory insufficiency and low blood pressure. Additionally, she was noted to have a white blood cell count in excess of 31,000, and due to the constellation of symptoms, an infectious disease consultation was requested to assist with this case. At bedside, the patient is a fairly poor historian and does not speak English. Therefore, data was derived via the help of a translator, as well as review of the chart and discussion with the patient’s caregivers. Upon her presentation, her family members noted that she had sustained a colon infection, and the patient had a positive Clostridium difficile toxin. She has had some mild shortness of breath as well as significant diarrhea. There are no upper gastrointestinal complaints such as nausea or vomiting.
PAST MEDICAL HISTORY: As above as well as hypertension, osteoporosis, obesity, asthma, hypothyroidism, and multiple sclerosis.
PAST SURGICAL HISTORY: Cholecystectomy, hysterectomy, ventral hernia repair, and subdural hematoma evacuation.
SOCIAL HISTORY: No tobacco, no alcohol, no drug use.
FAMILY HISTORY: Noncontributory.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: As stated in the history of present illness, this patient is not a very good historian and therefore a comprehensive review of systems is as listed above. A good portion of the data is derived from the review of the chart and discussion with the patient’s caregiver and is listed above.
MEDICATIONS: Current medication list is reviewed and includes Zosyn and Flagyl.
PHYSICAL EXAMINATION: Upon initial evaluation, the patient is afebrile. Pulse is 106, respirations 24, blood pressure 106/56. In general, she is a (XX)-year-old female, appearing her stated age. She is somnolent but arousable, in moderate distress at rest. Her head is normocephalic and atraumatic. Extraocular muscle movements are intact. No scleral icterus. Oropharynx is clear. Head and neck are free of palpable adenopathy. Her heart is tachycardic at 106 beats per minute. There is no auscultated rub. Lungs are with few basilar crackles bilaterally. No wheeze. Percussion is normal. Abdomen has positive bowel sounds. Soft with significant tenderness in the left lower quadrant to moderate palpation. There is no rebound, rigidity, or guarding. Lower extremities are without clubbing or cyanosis. Neurologically, she is nonfocal with normal cranial nerves.
DATABASE: A complete blood count, basic metabolic profile, full microbiological database have been reviewed. The case was discussed with multiple caregivers here in the emergency department and further recommendations from Infectious Disease is to follow.
IMPRESSION:
1. Sepsis syndrome in a patient with at least three of four criteria for systemic inflammatory response syndrome.
2. Respiratory insufficiency as part of a primary process such as would be associated with pneumonia or congestive heart failure or secondary process related to sepsis syndrome.
3. Leukocytosis.
4. Recent Clostridium difficile associated disease, likely recurrence.
RECOMMENDATIONS:
1. Check urinalysis and urine culture.
2. Check blood cultures x3.
3. Follow up results of CT angiogram.
4. Recheck Clostridium difficile toxin.
5. Linezolid 600 mg IV q.12 h.
6. Add vancomycin 250 mg p.o. q.6 h.
7. Continue Flagyl and Zosyn for now.
8. Volume infusion and the patient may require blood transfusion.
