DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Urinary tract infection, sepsis.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old female who was admitted through the emergency department where she was brought by the paramedics after her neighbor found the patient quite unresponsive and weak. The patient was in poor condition and was felt to have some hypotension, tachycardia, tachypnea and felt that probably had been septic. We were asked to see the patient because of this. The patient was unable to give any good information, and most of the information has been obtained from her previous admission and from the emergency department evaluation.
The patient has had a previous admission during which she underwent a cholecystectomy because of acute cholecystitis. She had leukocytosis postoperatively and renal insufficiency but recovered from the problem. The patient has not had any other recent history.
PAST MEDICAL HISTORY: Also significant for hypothyroidism and hypertension and some old history of constipation.
PAST SURGICAL HISTORY: Aside from the previous cholecystectomy, she has had an appendectomy, hysterectomy, and deviated septum.
ALLERGIES: TAPE.
SOCIAL HISTORY: The patient does not smoke, does not drink, and lives alone. She has one child, who lives out of town.
REVIEW OF SYSTEMS: The patient denies any cough, shortness of breath or respiratory distress. She had no chest pain. She has had only problems with constipation as indicated before, but there is no nausea, vomiting, hematemesis or melena. She says she always gets an infection when she gets a Foley catheter, and she has had recurrent bladder infections. She denies any major symptoms and no back pain.
PHYSICAL EXAMINATION: The patient is alert and responsive but has very poor memory. She is confused. She has difficulty finding words. Her blood pressure is 112/72. Heart rate is about 74. Respiratory rate is at 22. HEENT shows no abnormalities in the head. The scalp is normal. The eyes show equal pupils, reactive to light and accommodation. Conjunctivae and sclerae normal. The nose is normal. The mouth and oral mucosa showed no lesions. The throat shows no abnormalities. The neck is supple. No neck vein distention. Carotid pulses are normal. The neck veins are flat. The thyroid is in the normal range. The chest is symmetric. Her lungs are basically clear. There are only occasional rhonchi, decreased breath sounds in the bases. The heart sounds are regular. There is a high-pitched systolic murmur at the apex radiating to the axilla and also a grade 1/6 at the left sternal border. No gallops and no rubs. Her abdomen is soft. There is an incision from her previous surgeries. They are all healed. There are no masses, no tenderness, no visceromegaly. No CVAT. External genitalia normal. She now has a Foley catheter. The urine appears to be slightly turbid. The extremities show no peripheral edema. No phlebitis. No muscle tenderness. Joints show signs of osteoarthritis. Neurological exam shows no focal findings. There is good motion in all extremities and good sensory exam. The cranial nerves are intact.
LABORATORY DATA: WBCs were at 14, hemoglobin of 14.2, hematocrit of 42.8, platelets of 396. Creatinine was at 1.6. Urinalysis showed greater than 50 wbc’s per high power field, 2+ bacteria and 4+ leukocytes.
ASSESSMENT: At this time, the patient has evidence of urinary tract infection, for which she has had problems with this in the past. The deterioration might have been associated with urosepsis.
PLAN: We will go ahead and treat her for gram negatives in the urine and give her one single dose of tobramycin along with Rocephin already started in the emergency department.
Thank you very much, Dr. Doe, for asking us to see the patient.
