DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Gram-positive bacteremia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman who has had a very complicated past medical and surgical history over the past several months. The patient was initially operated on for ruptured appendix, which on surgical pathology turned out to be a perforation caused by carcinoid tumor. She then underwent hemicolectomy and postoperatively developed a fistula and abdominal wall abscess. The patient was then treated with a long course of TPN and antibiotics to resolve the fistula, and during the long course of TPN and antibiotics, the patient developed both Clostridium difficile colitis as well as a PICC line infection.
Following her PICC line infection, the patient had a new PICC line placed, so she could receive antibiotics for the old PICC line as well as continue TPN. The patient reports that all of these problems seem to be improving somewhat, and her diarrhea had finally tapered off. She has finished all of her antibiotics and was receiving some TPN through a PICC line uneventfully yesterday, when she developed the sudden onset of high fevers, shaking chills, sweats, headache, backache, diffuse myalgias, and arthralgias. She denied sore throat, cough, chest pain, abdominal pain, nausea, vomiting, worsening diarrhea, or dysuria. The patient then sought evaluation and was admitted to the hospital. Her PICC line was removed and the tip cultured earlier today. She started to improve somewhat after her admission and notes that she has not had any diarrhea for the past three or four days, which she attributes to the cessation of antibiotics about 10 days ago.
PAST MEDICAL HISTORY:
1. Carcinoid tumor, eventually requiring right hemicolectomy.
2. Abdominal wall abscess with fistulization as described above.
3. Hyperlipidemia.
4. Atrial fibrillation.
5. Hyperthyroidism.
6. Degenerative joint disease.
7. Psoriasis.
8. History of Clostridium difficile toxicity.
SOCIAL HISTORY: The patient continues to smoke cigarettes periodically but does not drink alcohol.
FAMILY HISTORY: Noncontributory.
ALLERGIES: NO TRUE ALLERGIES.
REVIEW OF SYSTEMS: Pertinent positives have been included in the history of present illness.
PHYSICAL EXAMINATION: Reveals a tired-appearing Hispanic woman, appearing older than her stated age. She is currently afebrile with blood pressure of 84/54, pulse 66, respiratory rate 22, and temperate maximum for today was 101.4. Examination of the head reveals no evidence of trauma. Pupils are equal, round, and reactive to light. The conjunctivae are normal. The oral cavity is without thrush or pharyngeal abnormalities. The neck is supple and without adenopathy. No thyromegaly is appreciated. The lungs are clear. The cardiac exam is currently regular rate and rhythm. The abdomen has some midline scar with a slight amount of distention but is essentially negative at this point. Lower extremities are unremarkable. No Foley catheter is present.
LABORATORY DATA: White count 5000, platelet count 106,000, and hematocrit 37. Urinalysis is negative. Creatinine 0.4. Liver function tests negative. TSH very suppressed at less than 0.007. Two blood cultures done on admission are growing gram-positive coccus. Preliminary results suggest this is not Staph aureus.
Chest x-ray shows a shrinking left basilar nodule.
IMPRESSION: This patient appears to have a PICC line infection. This is unfortunate given that one of the main purposes for this PICC line was to treat the infection, which developed from the prior PICC line. The patient’s focus of infection has been removed, and if this does turn out to be a coagulase-negative Staph, treatment of this should be relatively easy and can probably be done by the oral route over just a period of few days. The patient is currently without any symptoms of Clostridium difficile and hopefully this will not recur, as we are now giving the patient antibiotics again.
RECOMMENDATIONS:
1. The patient could be treated with vancomycin, Zyvox, or daptomycin while we await sensitivities. We note that the patient was just switched today from vancomycin to daptomycin, and while we are not certain if it was necessary to make that switch, we will not further muddy the waters by changing it back.
2. Flagyl can be given orally in a dose of 500 mg t.i.d. until we get back the Clostridium difficile, which has been ordered.
3. We would discontinue the Zosyn, which was started on the patient. Now that we have positive blood cultures, we think everything we can do to limit the risk of recrudescent Clostridium difficile will be in the patient’s best interest.
