DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Possible sepsis.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male with a history of diabetes and end-stage renal disease who presented to the hospital with altered mental status. Upon admission, the patient was found to have a fever of 100.8 degrees. He was also noted to be hypotensive. He was placed on IV fluids and dopamine and was suspected to have sepsis. The chest x-ray also showed possible pneumonia; therefore, Infectious Disease was consulted for further evaluation and management. Prior to our consultation, the patient was given one dose of vancomycin and was placed on cefepime. Upon our interview, the patient does appear mildly confused and somewhat lethargic. He reports that he had not been feeling good for several days, possibly with some nausea and fever. He denies any cough, shortness of breath, diarrhea or any other complaints. He is currently receiving oxygen via facemask.
PAST MEDICAL HISTORY: Hypertension, diabetes, dyslipidemia, end-stage renal disease, and peripheral vascular disease. The patient is on hemodialysis.
PAST SURGICAL HISTORY: Left upper extremity amputation, right BKA, and right IJ PermCath placement.
SOCIAL HISTORY: The patient denies tobacco, alcohol or illicit drug use.
FAMILY HISTORY: Noncontributory.
ALLERGIES: PENICILLIN WITH UNKNOWN REACTION.
CURRENT MEDICATIONS: Aspirin, Sensipar, NovoLog, Pacerone, Renagel, Nephro-Vite, and cefepime.
REVIEW OF SYSTEMS: Except for the above, no other cutaneous, neurologic, lymphatic, endocrine, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, or systemic complaints or events have been noted recently.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 99.4 degrees; blood pressure 126/54, the patient is currently off dopamine; pulse 68; and respiratory rate 18. The patient is on 15 liters of oxygen via facemask.
GENERAL: He is somewhat lethargic and mildly confused. There is no skin rash, generalized lymphadenopathy, cyanosis or jaundice.
HEENT: There is no conjunctivitis or rhinorrhea. There is no sinus tenderness or other intraoral lesions. He has mild oral thrush. There is no facial rash or otorrhea.
NECK: The patient has no nuchal rigidity, JVD or neck lymphadenopathy. There is no palpable neck mass.
HEART: There is no gallop, rub or murmur.
LUNGS: He has mildly decreased breath sounds on auscultation of the lungs.
CHEST: He has right upper chest wall Tesio catheter. The site is clean, dry, and intact with no evidence of surrounding cellulitis or necrosis.
ABDOMEN: There is no abdominal distension or tenderness. There is no palpable organomegaly. The bowel sounds are positive. There is no suprapubic or costovertebral tenderness.
EXTREMITIES: There are no cellulitis changes of the lower extremities. There is no joint tenderness or palpable subcutaneous nodules. There is no clubbing or edema. He has a left arm amputation, which appears to be below the elbow. He has a Foley catheter in place. He has a right BKA, and he has multiple excoriations to the left lower extremity with no evidence of surrounding cellulitis.
NEUROLOGIC: The neurologic exam is grossly intact without any new neurologic deficit.
LABORATORY DATA: White blood cell count 9.2, hemoglobin 10.8, hematocrit 32.6, platelets 112, creatinine 5.76, amylase 28, and lipase 9. Blood cultures are pending. UA is pending.
DIAGNOSTIC STUDIES: A chest x-ray showed increase in atelectasis, in infiltrate, and effusion at the left lung base.
ASSESSMENT AND PLAN: This is an elderly diabetic patient with end-stage renal disease, who was admitted for altered mental status and fever. Upon admission, he was noted to be hypotensive requiring some pressure support with vasopressors. He was also placed on vancomycin and cefepime. The patient was noted to have an abnormal chest x-ray. Currently, the patient is on 15 liters of oxygen and mildly confused. Admission to the ICU is currently pending. At this time, we cannot rule out a septic picture. The source of this is unknown. Currently, blood cultures are pending. We will follow up these results. We suspect either the septic picture is secondary to pneumonic process or a hemodialysis catheter-related bacteremia. It is okay to treat the patient with a combination of vancomycin, Azactam, and Zithromax empirically. We will check urine for Legionella antigen to rule out legionellosis. We will follow up with further recommendations as needed as laboratory results and culture results are obtained.
