Polymicrobial Sepsis Consultation Transcription Sample Report

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Streptococcus sepsis.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old woman with end-stage renal disease, on chronic renal dialysis, who was found to have streptococcus, isolated from her blood culture. Streptococcus pyogenes and Streptococcus agalactiae were isolated from her blood culture. In the meantime, her left forearm graft has a draining wound. The patient was admitted today to have the graft removal. The patient was treated with intravenous vancomycin prior to this admission. She had no shortness of breath, and she does not have any back pain. The patient had a graft infection in the past.

PAST MEDICAL HISTORY:
1. Chronic renal failure.
2. Hypertension.
3. Sepsis from a graft infection.
4. Status post PermCath insertion and subsequent removal, status post right arm AV graft surgery and status post left arm AV graft surgery.

ALLERGIES: NKDA.

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: The patient does not smoke and does not consume alcohol.

PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, pulse 82, respiratory rate 20, blood pressure 184/118. O2 saturation is 99%. She weighs 48.8 kilograms.
GENERAL APPEARANCE: A young woman sitting upright, comfortable.
HEENT: The patient had facial edema but no cellulitis.
NECK: Supple.
LUNGS: Trace crackles at the base.
HEART: Regular rate and rhythm with a 1 to 2/6 systolic murmur.
ABDOMEN: Soft and nontender.
EXTREMITIES: The patient had an AV graft on her right arm, which is not functional. She had an AV graft on the left forearm, and there is a boil along the graft with some purulent drainage.
NEUROLOGIC: The patient is awake and alert. She moved all four extremities spontaneously.

DIAGNOSTIC DATA: Blood culture grew Streptococcus pyogenes and Streptococcus agalactiae. Hemoglobin 11.8, sodium 130, potassium 37.8.

IMPRESSION:
1. Polymicrobial sepsis, probably secondary to a left forearm arteriovenous graft infection.
2. Left arm arteriovenous graft infection.
3. End-stage renal disease, on chronic renal dialysis.
4. Hypertension.

RECOMMENDATIONS:
1. Continue intravenous cefazolin 1 gram IV after the graft removal. The patient may need four weeks of IV antibiotics.
2. Echocardiogram.