DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Enterococcal bacteremia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old gentleman with about two months of abdominal pain, intermittent diarrhea, intermittent fevers, and malaise. CT scan of the abdomen disclosed diverticulitis with microperforation, and the patient was placed on Cipro and Flagyl. The patient was found to have a significant cardiac murmur and underwent a transthoracic echocardiogram, which showed rather severe aortic stenosis. He also underwent a left heart catheterization, which showed nonobstructive coronary artery disease. These cardiac studies were done in preparation for an anticipated surgery of the bowel, which is currently planned for tomorrow.
The patient was essentially afebrile throughout his stay but yesterday spiked a fever and developed a leukocytosis. Blood cultures done at that time have grown enterococcus, and an infectious disease consultation was requested. On interviewing the patient this afternoon, he is profoundly short of breath with a respiratory rate in excess of 30 after sitting up and defecating at the bedside commode.
He reports that he is often this short of breath with even minimal exertion. He states that he felt much worse yesterday, about the time the blood cultures were done, than on prior days with fevers, chills, and some worsening of his abdominal pain. He states that he has minimal cough, but he has chronic severe dyspnea on exertion. He denies chest pain at this time. He has been having intermittent loose stools, including a moment ago, and continues to have abdominal pain.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, alcohol abuse, aortic stenosis, and history of collapsed lung in the distant past.
ALLERGIES: CODEINE.
FAMILY HISTORY: Coronary artery disease.
SOCIAL HISTORY: The patient lives with his sister. He reports that he drinks five packs of beer a day and has smoked a pack of cigarettes a day for about the past 45 years.
REVIEW OF SYSTEMS: Done in its entirety. Pertinent positives included in the history of present illness.
PHYSICAL EXAMINATION:
GENERAL: Thin, chronically ill-appearing man, who appears much older than his stated age. He is currently dyspneic.
VITAL SIGNS: Most recent temperature is 99.2 degrees, but he did have a T-max of 102.8 degrees yesterday. His respiratory rate is currently around 30. His oxygen saturation measured currently is 82% on room air, and nasal oxygen has been started.
HEENT: Examination of the head reveals no evidence of trauma. The eyes have no conjunctival hemorrhages. Oral cavity, no thrush, no hairy leukoplakia or pharyngeal abnormalities.
LUNGS: Have scattered rhonchi bilaterally and generally poor airflow.
HEART: Regular rate and rhythm but 2/6 murmur that radiates in an aortic distribution.
ABDOMEN: Not distended and has only really minor tenderness in the left lower quadrant.
EXTREMITIES: There are no peripheral stigmata of endocarditis on the hands. The lower extremities are without edema or petechiae.
DIAGNOSTIC DATA: The CAT scan of the abdomen was noted to be consistent with diverticulitis and microperforation. Two blood cultures from yesterday are positive for enterococcus with sensitivities pending. White blood count has risen from approximately 10,500 to 12,500 on prior days to 15,500 today with platelet count 172,000, and creatinine 0.7.
IMPRESSION AND PLAN:
1. This patient has a nosocomial enterococcal bacteremia. When the patient came in, his white count was not as elevated as it was yesterday, then he was afebrile. The occurrence of the increasing white count and fever yesterday suggests probably that his enterococcal bacteremia is probably secondary to infected peripheral IV site or perhaps his diverticulitis. The possibility of endocarditis certainly exists in a patient with aortic stenosis, and we discussed this by telephone with a cardiology consultant. We felt that given the fact that his enterococcal bacteremia was nosocomial rather than community-acquired and that we had another obvious source other than his heart fails, namely his abdomen or IV, that he did not need a TEE before his surgery tomorrow. Should his enterococcal bacteremia be sustained, he certainly will require a transesophageal echocardiogram.
2. Drug recommendations. We will discontinue the Cipro and Flagyl that the patient was begun on since his admission.
3. Tigecycline could be used as a single antibiotic in this situation as it treats enterococcus as well as common gram-negative rods and anaerobes.
4. The patient is cleared for surgery from an ID point of view tomorrow.
5. Blood cultures x2 will be repeated today.
