DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation of epidural abscess.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who began complaining of pain with walking. He also had a fever. He was brought to the emergency department for evaluation. The patient had a high white cell count and sedimentation rate and was referred for admission. Eventually, the blood culture grew methicillin-resistant Staphylococcus aureus. Further evaluation revealed the presence of an epidural abscess at the level of L4-S1. Today, the patient underwent an L4-L5 laminectomy and the abscess was evacuated. The procedure was performed under general anesthesia. There were no intraoperative complications reported. Following the surgery, the patient recovered and was then admitted to the intensive care unit.
PAST MEDICAL HISTORY: Details of the past medical history have been reviewed in the medical record.
ALLERGIES: He has no known drug allergies.
IMMUNIZATIONS: Reported to be up to date.
MEDICATIONS: He was not receiving medications prior to admission.
He had no significant illnesses, trauma or hospitalizations prior to this admission.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, well-nourished Hispanic male who is asleep in bed postoperatively.
VITAL SIGNS: Temperature 99.2 degrees orally. Weight has not been measured.
CENTRAL NERVOUS SYSTEM: He is asleep but easily arousable. His pupils are equal, round, and reactive. His facial features are symmetrical. He has symmetrical movements of his upper and lower extremities with normal tone and strength.
HEENT: Head is normocephalic and atraumatic. Sclerae anicteric and conjunctivae are pink. Oral mucosa is moist and palate is intact.
NECK: Supple. He has no lymphadenopathy or palpable masses.
LUNGS: He is breathing comfortably with respiratory rate in the 20s. His breathing is unlabored. His breath sounds are clear. Saturations are 98% on room air.
HEART: Heart rate is 114 and blood pressure 108/52. Heart sounds are normal. He has no murmur, gallop or rub.
ABDOMEN: His abdomen is soft. He has positive bowel sounds. He has no organomegaly or palpable masses.
EXTREMITIES: Extremities are warm and well perfused. Extremities have normal muscle bulk and tone. He has no clubbing, cyanosis or edema.
SKIN: Warm and dry.
BACK: His surgical incision is intact. The surgical dressing is intact.
IMPRESSION:
1. Fever and difficulty walking prompting admission.
2. Methicillin-resistant Staphylococcus aureus bacteremia and epidural abscess.
3. Status post L4-L5 laminectomy with evacuation of abscess.
PLAN:
1. Cardiopulmonary and neurologic monitoring.
2. Pain medications as needed.
3. Antimicrobial therapy.
4. Ongoing infectious disease evaluation.
5. Diet as prescribed by Neurosurgery.
6. Monitor electrolytes and hematologic studies.
