DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Resistant infection.
CHIEF COMPLAINT: Resistant infection.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with a history of acute diverticulitis requiring subsequent partial colectomy and the subsequent development of a complicated wound infection. The patient presented to the emergency department with complaints of chest pain. She was seen and evaluated by the emergency department physician and is currently being followed closely by Dr. John Doe for any cardiopulmonary issues. However, the patient still has a chronic abdominal wound, which is being treated with a vacuum-assisted closure device. In the emergency department, a wound culture was obtained, and this culture was noted to be positive for MRSA. An infectious disease consultation was requested to assist with this case. At bedside, the patient denies complaints of fevers, sweats or chills. She has no peripheral leukocytosis or evidence of systemic inflammatory response. The patient does complain of some poorly descriptive and very mild abdominal discomfort. She denies dysuria, nausea or vomiting.
PAST MEDICAL HISTORY: As above as well as hypertension, COPD, congestive heart failure, and myocardial infarction.
PAST SURGICAL HISTORY: As above.
SOCIAL HISTORY: No tobacco, no alcohol, no drug use.
FAMILY HISTORY: No immune dysfunction.
ALLERGIES: MULTIPLE MEDICATION ALLERGIES, SEE CHART.
REVIEW OF SYSTEMS: A 14-system review of systems is as per HPI, otherwise negative.
CURRENT MEDICATIONS: List reviewed.
PHYSICAL EXAMINATION:
VITAL SIGNS: Upon initial evaluation, the patient is afebrile, pulse 72, respirations 18, and blood pressure 130/68.
GENERAL: The patient is a (XX)-year-old female appearing her stated age. She is alert and oriented x3, in minimal distress at rest.
HEENT: Head is normocephalic and atraumatic. Extraocular muscle movements are intact. No scleral icterus.
CARDIOPULMONARY: Status is stable.
ABDOMEN: Positive bowel sounds, soft, minimally tender somewhat diffusely but there clearly is no rebound, rigidity or guarding. Centrally located, there is an approximately 6.5 x 4.5 cm wound with a vacuum-assisted closure device in place. There is no circumferential erythema. No necrotic tissue. As mentioned above, a full exam could not be completed as the VAC is in place and cannot be replaced without the presence of the specific VAC nurse. Due to the patient’s nontoxic condition, we do not see any reason to pursue this further on this occasion but plan on obtaining either close photodocumentation or exam at the next scheduled VAC change date.
NEUROLOGIC: Neurologically, she is otherwise nonfocal.
EXTREMITIES: Lower extremities are without clubbing or cyanosis.
Complete blood count, basic metabolic profile, full microbiologic data, all have been reviewed. The case was discussed with multiple caregivers and further recommendations are to follow.
IMPRESSION:
1. Methicillin-resistant Staphylococcus aureus, wound culture, noted from the patient’s chronic abdominal wound. This appears to be nothing more than colonization, but an increased bioburden can often delay the healing process.
2. History of a complicated wound infection, status post acute diverticulitis with partial colectomy and multiple repeat surgical procedures.
3. Mild abdominal discomfort.
RECOMMENDATIONS:
1. Place the patient on contact isolation.
2. Continue with the current vacuum-assisted closure device.
3. More thorough examination of the wound bed when the vacuum-assisted closure is removed or obtain photodocumentation.
4. Check urinalysis and urine culture.
5. Amylase and lipase.
6. Three-view abdominal film.
