DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Resistant infection.
CHIEF COMPLAINT: Fatigue.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with a history of type 2 diabetes mellitus, pancreatitis, and chronic hepatitis C who presented with complaints of fever and generalized malaise. He was seen and evaluated by the emergency department physician and subsequently admitted to the care of Internal Medicine. The patient was noted to have fevers, and blood cultures were obtained. These blood cultures were noted positive for gram-positive cocci. The patient also was noted to have a urine study positive for MRSA. An infectious disease consultation was requested to assist with this case.
At bedside, the patient explained that he underwent a cystoscopy for chronic obstructive uropathy, and subsequently, the patient underwent a prostatic biopsy, which was noted to be negative for malignancy. The patient also underwent the insertion of an UroLume for chronic obstructive uropathy, which gave him good results at that particular time. A few days later, the patient began to experience generalized malaise and then presented with fever and chills. Initially, the patient’s urine culture was noted to be positive for MRSA and one of two blood cultures were positive. This prompted the infectious disease consultation, but by the time we arrived, both blood cultures were noted positive for gram-positive cocci in clusters.
PAST MEDICAL HISTORY: The patient’s past medical history includes that which is mentioned above as well as hypertension, history of generalized anxiety, and panic disorder, which is the source of his disability.
PAST SURGICAL HISTORY: Includes that which is mentioned above.
SOCIAL HISTORY: The patient has an extensive history of alcohol use. He lives locally by himself.
FAMILY HISTORY: No immune dysfunction other than diabetes.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: A 14-system review is as per history of present illness, otherwise negative.
CURRENT MEDICATIONS: List is reviewed.
PHYSICAL EXAMINATION:
VITAL SIGNS: Upon my initial evaluation, he has got a T-max of 100.2 degrees Fahrenheit, pulse 104, respirations 20, and blood pressure 120/70.
GENERAL: The patient is a (XX)-year-old male appearing his stated age. He is alert and oriented x3, in no apparent distress at rest.
HEENT: His head is normocephalic and atraumatic. Extraocular muscle movements are intact. No scleral icterus. Oropharynx is clear.
NECK: Free of palpable adenopathy.
HEART: Regular at 100. No auscultated rub.
LUNGS: Clear to auscultation and percussion bilaterally. No rhonchi and no wheezing.
ABDOMEN: Positive bowel sounds, soft, nontender, and nondistended. No rebound, rigidity, or guarding.
EXTREMITIES: Lower extremities are without clubbing or cyanosis.
NEUROMUSCULAR: Neurologically, he is nonfocal with normal cranial nerves. Muscle strength is normal in the upper extremities.
LABORATORY STUDIES: A complete blood count, basic metabolic profile, full microbiologic database, all of which have been reviewed.
IMPRESSION:
1. Methicillin-resistant Staphylococcus aureus urinary tract infection in a patient who has recently undergone a genitourinary procedure for outlet obstruction.
2. Gram-positive bacteremia noted in 2 of 2 blood culture sets. We obviously need to rule out methicillin-resistant Staphylococcus aureus bacteremia.
3. Type 2 diabetes mellitus with poor control.
4. Fever.
RECOMMENDATIONS:
1. Place the patient on contact isolation.
2. Follow up blood culture.
3. Repeat blood cultures x2.
4. Start vancomycin.
5. Discontinue Zosyn.
6. Obtain transthoracic echocardiogram.
7. The case is discussed with multiple caregivers and further recommendations from Infectious Disease are to follow.
Thank you for this interesting consult and allowing us to participate in this patient’s care.
