CONSULTANT: John Doe, MD

REFERRING PHYSICIAN: Jane Doe, MD

REASON FOR CONSULTATION: Bilateral pneumonia.

HISTORY OF PRESENT ILLNESS AND HOSPITAL COURSE: The patient is an (XX)-year-old female with history of multiple medical problems including severe chronic obstructive pulmonary disease, atrial fibrillation/congestive heart failure, severe osteoarthritis and osteoporosis with a history of multiple vertebral fractures and recently diagnosed chronic myelogenous leukemia who has been on chemotherapy for leukemia.

The patient was recently discharged from an outside hospital after treatment for osteoporotic vertebral fracture with kyphoplasty and subsequent rib fracture. The patient was reportedly unable to move much because of the rib fracture and gradually developed shortness of breath and cough.

She was brought to the emergency room because of increasing shortness of breath and possible seizure-type episode. The patient was found to have severe bilateral pneumonia with ground-glass appearance, particularly on the left side, and in moderate hypoxemia, requiring intubation.

The patient had bronchoscopy and bronchoalveolar lavage done soon after admission, and the Gram stain showed 2+ wbc’s, 2+ gram-positive rods with normal respiratory flora on culture. AFB smear was negative and Legionella DFA was also negative. PCP stains are negative at this time.

The patient’s white count was 52,000 at admission with only low-grade fever. CT of the chest showed bilateral pleural effusion and right lower lobe atelectasis as well as diffuse interstitial infiltrates, left more than right.

The patient was started empirically on intravenous imipenem, Levaquin and fluconazole, and has improved since admission and actually was successfully extubated this morning. Her subsequent chest x-ray had showed some improvement in the right lower lobe atelectasis, but the diffuse infiltrates remained unchanged.

Her ABGs today on 60% FiO2 showed a pH of 7.35, pCO2 43, pO2 67.2, bicarbonate 23 and saturation 94.4%. Her white count has come down from 52,000 down to 18,400, and she is afebrile currently.

REVIEW OF SYSTEMS: Respiratory: As described above. Minimal sputum production and no hemoptysis or pleuritic pain reported. Gastrointestinal: No abdominal pain, nausea, vomiting, diarrhea, hematochezia or melena. Cardiac: No angina-type pain, orthopnea, palpitations or syncopal episodes. Genitourinary: No dysuria, hematuria, urinary frequency, nocturia or flank pain. General: No fever or chills. No sore throat, postnasal drip or nasal discharge.

SOCIAL HISTORY: The patient used to be a smoker. No history of alcohol or drug abuse.

PAST MEDICAL HISTORY: As above. History of coronary artery disease; atrial fibrillation; congestive heart failure; severe osteoarthritis and osteoporosis with multiple vertebral fractures; severe chronic obstructive pulmonary disease; history of pneumonias in the past, one time requiring tracheostomy; chronic myelogenous leukemia, diagnosed recently; history of tuberculosis in 1950 for which she had partial resection of a segment of right lower lobe; history of dissecting aneurysm for which she had surgery couple of years ago; history of gastroesophageal reflux disease.

MEDICATIONS AT ADMISSION: Lasix, potassium, Aldactazide, Norvasc, allopurinol, Synthroid, hydroxyurea, Carafate, Miacalcin, Xalatan and other eye drops. The patient is also on nebulizer therapy, aspirin and was on Augmentin for a few days as outpatient.

PAST SURGICAL HISTORY: Significant for back surgery, spinal fusion in the neck, aneurysm repair, tuberculoma removed from the right lower lobe.

ALLERGIES: NO KNOWN DRUG ALLERGIES.

FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION: General: The patient is an elderly female who is lying in bed and appears to be in no acute distress, currently on oxygen via mask. Vital Signs: Current vital signs are stable with a pulse of 82 per minute, saturation 94% on 60% FiO2. HEENT: No gross pallor or icterus. Oral mucosa is slightly dry with some missing teeth. Neck: Supple with no jugular venous distention, thyromegaly or lymphadenopathy. Chest: Respiratory movements are symmetrical and minimally labored. Air entry is fair bilaterally with few scattered rales and few rhonchi bilaterally. Cardiac: S1 and S2 with regular rhythm. No gross murmurs or rubs. Abdomen: Nondistended and soft with no focal tenderness, rebound or rigidity. No gross hepatosplenomegaly or palpable masses. Bowel sounds are positive. Extremities: No pedal edema. Pedal pulses are diminished. Few ecchymotic lesions. No gross rashes. No evidence of cellulitis. Neurologic: The patient is alert and well oriented with no focal deficits.

PERTINENT INVESTIGATIONS: Chest x-ray showed bilateral upper and lower lobe infiltrates with loss of volume on the right side. X-ray from today showed improved atelectasis of the right lower lobe. Most recent ABGs as described above. Most recent CBC shows a white count of 18,400 with 90% neutrophils. Bronchoalveolar lavage unremarkable so far. Blood cultures negative.

ASSESSMENT: Bilateral pneumonitis of unclear etiology in an immunosuppressed patient with a recently diagnosed chronic myelogenous leukemia, who was on chemotherapy. The patient also has underlying chronic obstructive pulmonary disease. Extensive interstitial infiltrates, left side more than the right, as well as right lower lobe atelectasis at admission. Now, much improved with resolving atelectasis and was successfully extubated this morning. She is still hypoxic with pO2 in the 60s on 60% FiO2. She is currently on intravenous imipenem, levofloxacin and fluconazole and microbiologic workup negative so far. This clinically appears to be a subacute-to-acute process. Rule out atypical pneumonia versus mycobacterial infection. Rule out noninfectious etiology. Pneumocystis carinii pneumonia is a possibility, although less likely, as there is no history of chronic steroid use.

RECOMMENDATIONS: Continue with current antibiotic coverage including intravenous imipenem and Levaquin that is covering all possible bacterial and atypical bacterial etiologies. We will check Legionella urine antigen and serologies and await AFB cultures. PPD might not be useful because of history of tuberculosis in the past.

Thank you, Dr. Doe, for this consult. I will follow the patient along with you.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Acute meningitis.

HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic female, visiting here from another city, presented with severe headache,, which started two days prior to admission. The patient reports that she has been having neck pain for the last three weeks. She was seen by her primary care physician, given some muscle relaxant, without significant relief. She did have some scratchy feeling in the throat and was seen by another physician about a week to 10 days ago and was prescribed Z-Pak. The sore throat resolved. The patient continued having neck pain and stiffness, and she came to this city on Wednesday. Thursday night, the patient started having headache, mostly bitemporal area on the back of the head. The patient did take some Tylenol with a little bit of relief.

By Saturday evening, headache was 10/10, throbbing, and the patient presented to the emergency department. In the ED, upon arrival, the patient had a temperature of 98.4, pulse 98, respiratory rate 16, blood pressure 144/94, O2 sat 99% on room air. Labs revealed leukocytosis. The patient also underwent spinal tap, which revealed wbc’s 674 with polys 79%, lymphocytes 12%, rbc’s 224, glucose 56, and total protein 80 consistent with acute meningitis.

Infectious disease consult has been obtained for further evaluation and management of this patient. The patient has been empirically started on IV ceftriaxone and vancomycin. The patient does state that she has been having a history of recurrent labial herpes and has been recently diagnosed with hypothyroidism. The patient did have nausea and vomiting this morning. The patient also reports a few loose bowel movements last Thursday, which has now resolved.

PAST MEDICAL HISTORY: Hypothyroidism and history of viral meningitis approximately seven years ago.

PAST SURGICAL HISTORY: Status post cholecystectomy secondary to gallstones.

ALLERGIES: NKDA.

HOME MEDICATIONS: Synthroid, Tylenol and Motrin p.r.n., birth control pills, and multivitamins.

FAMILY HISTORY: Mother died of abdominal aortic aneurysm. Sister has some stomach motility disorder.

SOCIAL HISTORY: The patient lives with husband and kids. The patient denies smoking, occasional alcohol intake. Denies illicit drug use.

REVIEW OF SYSTEMS: As per history of present illness, positive for neck pain and stiffness for the last three weeks, worsening headache for the last two days associated with nausea, vomiting, and fever. Denies any abdominal pain. Did have diarrhea last Thursday, which has been resolved now. Did have a sore throat a couple of weeks ago, treated with Z-Pak, resolved now. Denies any visual or hearing deficits. Denies any stuffy nose, cough, sputum, shortness of breath, palpitation, dizziness, and denies any rash. Denies any focal weakness. Appetite fair. No significant weight change. Denies any dysuria, frequency of urination. Rest of the review of systems is unremarkable.

PHYSICAL EXAMINATION: Vital Signs: Temperature 99.6, pulse 74, blood pressure 138/72, respiratory rate 18, and O2 sat 97% on room air. The patient is a well-nourished, young Hispanic female lying on bed without any obvious distress, pleasant and cooperative with history and physical examination. Pupils are equal, round, and reactive to light bilaterally. Extraocular movements are intact bilaterally. HEENT: Clear. Neck with mild stiffness. No scalp tenderness noted. No lymph node, JVD or thyroid noted. Lungs are clear to auscultation bilaterally. Heart: S1 and S2 audible. No S3 or murmur noted. Abdomen: Protuberant, soft, nontender. Good bowel sounds, difficult to palpate any visceromegaly. Neurologically, the patient is awake, alert, and oriented x3. No gross motor or sensory deficits noted. Extremities: No clubbing, cyanosis or edema noted.

LABORATORY DATA: WBC count 30.6, hemoglobin 14.2, hematocrit 40.8, and platelet count 264,000. Serum sodium 139, potassium 4.1, chloride 104, bicarb 26, glucose 120. BUN 12, serum creatinine 0.9. Pregnancy test negative. CSF revealed hazy and pink wbc’s in tube one, 675; tube two, 450. RBCs in tube one, 225; tube two, 225. Xanthochromia negative and differentials in CSF revealed polymorphonucleocytes 79%, lymphocytes 12%, monocytes 7%, eosinophils 2%. CSF glucose 56. CSF protein 80, which is elevated. CSF smear revealed 3+ wbc’s, no organisms. Culture revealed no growth to date. Bacterial antigen detection test negative.

CT of brain unremarkable.

PROBLEMS:
1. Acute meningitis, differential diagnosis as discussed above.
2. Low-grade fever, most likely secondary to above.
3. Leukocytosis secondary to above.
4. Headache secondary to above.
5. Hypothyroidism.

ASSESSMENT: This young Hispanic female with past medical history of hypothyroidism and viral meningitis about seven years ago now presented with neck pain for the last three weeks and severe headache for the last two days with fever, chills, found to have neck stiffness and leukocytosis. Cerebrospinal fluid consistent with acute meningitis, most likely aseptic meningitis, viral in etiology considering normal glucose and elevated protein, but possibility of partially treated bacterial meningitis and herpes simplex virus meningitis cannot be excluded as the patient did take Z-Pak about a week ago and does have a history of recurrent orolabial herpes and rbc’s in the cerebrospinal fluid.

RECOMMENDATIONS:
1. We agree with the IV ceftriaxone and vancomycin pending final CSF culture results.
2. Start acyclovir 10 mg/kg IV q. 8 hours. Discussed with the patient in detail a very low likelihood that she will have HSV meningitis, but considering recurrent orolabial herpes and rbc’s in the CSF, it cannot be excluded; so the patient expressed her willingness to be treated with acyclovir and willing to take the risk of side effects with acyclovir, like blood dyscrasias and other side effects discussed with the patient in detail.
3. Add HSV PCR to already drawn labs. If it turns out negative, we will discontinue acyclovir.
4. We will follow the CSF culture results.
5. Pain control.

The plan was discussed with the patient and nursing staff in detail. Further recommendations to follow.

HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old Hispanic male who was in his usual state of health until he developed ptosis of his left eyelid and a cranial nerve III palsy. He has had diplopia. He has been evaluated by Oculoplastics, Neurosurgery, and Neurology. He had an MRI of the brain, which had some abnormalities, and this was followed by an MRA, which showed no evidence of a vascular flow problem. He has been given a diagnosis of Tolosa-Hunt syndrome. He has been placed on intravenous steroids as therapy for this. Infectious Disease consultation was requested for evaluation from an infection standpoint.

PAST MEDICAL HISTORY: The patient denies any past medical history.

PAST SURGICAL HISTORY: The patient denies any past surgical history.

MEDICATIONS: Protonix, Zofran, acetaminophen, and lorazepam.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient does not drink or smoke. He lives at home with his wife and two children, all of whom are well at this time. There has been no recent travel.

REVIEW OF SYSTEMS: No fevers. Positive chills episodically. No diarrhea. Positive nausea. No skin rash.

PHYSICAL EXAMINATION: The patient is an awake, alert, oriented male currently in no acute distress. Temperature is 98.2, and there have been no febrile spikes since the patient has been hospitalized. Pulse 64, respirations 18, and blood pressure 102/60. Weight is 67.2 kilos. Neck is supple. Mucous membranes are pink and moist. Sclerae are nonicteric. The left eye is notable for complete ptosis. The patient has some double vision when the eyelid is retracted. Conjunctivae are without injection, however. No anterior or posterior cervical adenopathy. No thyromegaly. No supraclavicular, axillary or epitrochlear adenopathy. Lung fields are clear to auscultation. No rales, rhonchi or wheeze. Heart has a regular rate and rhythm. No murmur, rub or gallop. Abdomen is soft and nontender. Positive bowel sounds diffusely. No hepatosplenomegaly. No guarding or rigidity of the abdomen. No abdominal tenderness. GU and rectal exams were deferred. Extremities with no palmar or plantar rash. The patient has a wart overlying the proximal interphalangeal joint on the fourth digit of the right hand. Nail beds are pink. Extremities without gross deformities. The skin is without rash.

DIAGNOSTIC DATA: The patient has had a CT, MRI, and MRA of the brain. MRI of the brain was remarkable for normal study. MRA was remarkable for normal study as well. CT scan of the head without contrast showed no evidence of masses. CT scan of the orbits was without abnormality. Chest x-ray performed was without abnormality.

LABORATORY DATA: White count 5.6. H&H are 14.2 and 41.6. Platelet count 356. PT/PTT are 11.4 and 31.2. Serum sodium 140, potassium 4.1, chloride 102, CO2 of 28. BUN and creatinine are 11 and 0.9. AST and ALT are 13 and 39. Lyme serologies as well as ACE level are pending at this time. The patient underwent LP and spinal fluid was without any white cells. Normal protein was evident. Sedimentation rate is 33. C-reactive protein is 0.18.

IMPRESSION:
1. A patient with third nerve palsy and left eye ptosis with diagnosis of Tolosa-Hunt syndrome.
2. No obvious sign of infection origin at this time.
3. Would have to rule out Lyme disease, however.
4. No obvious evidence of parasitic infection.

RECOMMENDATIONS:
1. We will check stool for ova and parasites.
2. Consider treating the patient empirically with a round of albendazole.
3. We will check Lyme, Western blot, and MHA-TP for indirect measure of Lyme disease. If these are positive, the patient would require intravenous antibiotics.

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Pneumonia, persistent leukocytosis, rule out Clostridium difficile and urinary tract infection.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man with multiple medical problems that include multiple myeloma with infiltrating amyloidosis of lower extremities. The patient’s course was complicated with history of DVT, also compression fracture of L3. In addition to that history, he also has a history of atrial fibrillation, renal cell CA, status post nephrectomy, osteoarthritis, as well as sacral decubitus stage I of the coccyx.

He was admitted to the hospital and transferred from extended care facility with progressive shortness of breath and possible pneumonia. The patient was found to be hypoxic. There was no evidence of fever. Chest x-ray was obtained, which showed bibasilar infiltrates. Empirically, he was started on IV Rocephin and Zithromax. While on treatment, he remained stable in regards to his oxygen saturation, and he had no increasing shortness of breath. His white count continued to increase. Urine culture came back positive for coagulase-negative staph, and he was started empirically on p.o. Bactrim. When his white count continued to climb, p.o. Flagyl was added as well. Infectious disease consult was called to evaluate the patient, to assist for treatment.

PAST MEDICAL HISTORY: As mentioned above.

ALLERGIES: PENICILLIN.

SOCIAL HISTORY: The patient is married with one child. The patient has a positive history of smoking for many years. No ETOH or drug use.

FAMILY HISTORY: Positive for diabetes.

CURRENT MEDICATIONS: The patient is currently on Duragesic, Flagyl 500 mg q. 6 hours, Bactrim Double Strength one b.i.d., Ventolin, Percocet, Ambien, and Remeron. He is also on Zithromax 250 mg IV daily, ceftriaxone 2 grams IV daily, and Tylenol.

REVIEW OF SYSTEMS:
CONSTITUTIONAL: The patient denies cough or shortness of breath. No fevers or chills. No headaches. No dizziness.
ABDOMEN: No abdominal pain. Positive diarrhea.
GENITOURINARY: No urinary frequency or urgency.

PHYSICAL EXAMINATION:
GENERAL: The patient is in no acute distress but appears very frail.
VITAL SIGNS: His T-max is 100.6, BP 126/82, and heart rate 80.
HEENT: Pupils are reactive. Conjunctivae are pale. No icterus. No conjunctival hemorrhage.
NECK: Supple. No JVD. Some lymph nodes palpable.
LUNGS: Clear to auscultation. Occasional crackles. No rhonchi or wheezes.
HEART: S1, S2 regular without gallop or murmur.
ABDOMEN: Soft. Bowel sounds are present. No tenderness to palpation. No hepatosplenomegaly.
EXTREMITIES: They are atrophic. There are some skin changes with yellowish discoloration. Pulses are 2+.
NEUROLOGIC: He is awake, alert, and oriented x3. No focal deficits. His coccyx area has a stage I decubitus.

LABORATORY AND DIAGNOSTIC DATA: WBC count 42.8, hemoglobin 10.4, and platelets 414. Creatinine is 0.9. Urine culture, coagulase-negative staph. C difficile is pending and blood cultures pending. Chest x-ray: Bibasilar infiltrates.

ASSESSMENT: This is a (XX)-year-old man with history of multiple myeloma, atrial fibrillation, deep venous thrombosis, renal cell carcinoma, amyloidosis, as well as L3 compression fracture. The patient was admitted now with increased shortness of breath and bibasilar pneumonia. He has been treated with Rocephin and Zithromax but developed increasing white count up to 42.9, and he also developed diarrhea. His urine culture is positive for coagulase-negative staph.

PLAN:
1.  Leukocytosis, most likely secondary to C difficile. We agree with p.o. Flagyl, with the change to p.o. t.i.d. 500 mg.
2.  Pneumonia. Will check Legionella antigen, and if negative, would discontinue Zithromax IV. The patient could be changed to Zithromax and finish course of 14 days.
3.  UTI. On Bactrim for coagulase-negative staph. We would repeat UA and urine cultures.

REASON FOR CONSULTATION: Antibiotic management of postsurgical abscess.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who underwent an intramuscular lipoma resection on the back of her neck with Dr. John Doe of neurosurgery. She was doing well postoperatively until five days ago when she woke up with intense pain and decreased range of motion of her neck. She denies any fevers, chills or rigors at this time; however, she does note that her son reported that the wound site was swollen and indurated.

The patient was seen by the neurosurgery service, who obtained a superficial culture of the dehisced incision site and she was taken to the OR by Dr. Jane Doe for incision and drainage. She evacuated pus in the intramuscular layers of the neck and obtained deep cultures as well. Following the incision and drainage, she has been started on vancomycin and cefepime.

PAST MEDICAL AND SURGICAL HISTORY: Pertinent for nephrolithiasis requiring stent placement; asthma, does not require treatment; history of easy bruising. The patient is status post laparoscopic hysterectomy and laparoscopic endometrial repair.

CURRENT MEDICATIONS: Percocet, vancomycin, cefepime, albuterol, Zofran, and senna.

ALLERGIES: Sulfa drugs and macrolide antibiotics.

FAMILY HISTORY: Positive for breast cancer in her sister.

SOCIAL HISTORY: The patient is married. She lives at home with her husband and her one son. She has never used recreational drugs. Currently smokes a few cigarettes a day but in the past has smoked up to 20 for a 10-20 pack-year history, and she is a social drinker.

REVIEW OF SYSTEMS: A 10-point review of systems was performed, and it is pertinent only for that she also states that she did have limited range of motion since the initial neck surgery by Dr. John Doe and a mild decrease in appetite. Otherwise, all reviewed systems were negative.

PHYSICAL EXAMINATION:
GENERAL: The patient is a female appearing her stated age, in no acute distress, in a soft collar.
VITAL SIGNS: Blood pressure is 120/80, heart rate 64, respiratory rate 18, temperature 36.6 degrees, and she is satting at 97% on room air.
HEENT: Reveals no ocular petechial hemorrhages, benign-appearing oropharynx without any lesions or petechiae.
NECK: Reveals mild cervical lymphadenopathy and decreased range of motion due to discomfort. Postsurgical drainage site is midline on her neck. Bandage is oozing some faint serous fluid and is mildly tender to touch.
LUNGS: Clear to auscultation bilaterally.
HEART: Reveals regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Reveals good bowel sounds in all four quadrants, nontender, nondistended. She has no hepatosplenomegaly.
EXTREMITIES: Reveals no significant edema, good distal pulses, no evidence of any skin breakdown on her feet.
NEUROLOGIC: She has a symmetric neurologic examination of her upper extremities and of her face, essentially nonfocal. She is awake, alert, and interactive.

CURRENT LABORATORY DATA: Sodium 140, potassium 4.0, chloride 109, bicarbonate 24, glucose 80, BUN 10, creatinine 0.8, calcium 9.8. White blood cell count is 11.5, hemoglobin 13.8, hematocrit 43.2, and platelet count 252,000. Sed rate 24. Initial culture and deep cultures obtained during incision and drainage are all growing Staph. aureus.

ASSESSMENT AND PLAN: The patient is a (XX)-year-old woman with a postsurgical Staphylococcus aureus abscess over posterior neck, incision successfully drained. She is doing quite well since the drainage. Given that culture results are growing Staphylococcus aureus at this time, we can continue the IV vancomycin for now pending sensitivities of the culture results but feel it is okay at this point to discontinue the cefepime.

We will plan for an oral antibiotic regimen to be determined once we have the sensitivities of the Staph. aureus result to transition her over to at the time of discharge. Given that we should have the sensitivities back in a day or so, we do not need to continue checking levels on vancomycin.

REQUESTING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Rule out sepsis, question septic thrombophlebitis, and fever.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with a past medical history significant for morbid obesity, history of hypertension, and recurrent bilateral lower leg cellulitis in the past. She also has a history of repeated sinusitis, psoriasis, mitral valve prolapse, osteoarthritis, a history of right knee arthroscopy, and chronic leg edema. The patient was recently admitted, and she was treated for leg cellulitis. Approximately one week ago, she started experiencing cough and was not feeling well. The patient came to the ER where she was given Zithromax. Blood cultures were drawn and she was discharged home. Blood cultures from that day grew two out of three sets of bacillus species. The patient, at home on Zithromax, failed to improve. She had increased weakness and also developed fever up to 103. She continued to have cough. The patient was also complaining of increased swelling in the right upper extremity at the site where she had a PICC line. An ultrasound of that arm was done, which was negative for DVT. The patient was started on heparin empirically. Infectious Disease consult was called to evaluate the patient and assist with treatment.

PAST MEDICAL HISTORY: As mentioned above.

CURRENT MEDICATIONS: The patient is on Bumex 1 mg p.o. b.i.d., Motrin 600 mg p.o. q.6 h., Ventolin, Tylenol, Lopressor 25 mg p.o. b.i.d., heparin per protocol, moxifloxacin 400 mg IV daily, and clindamycin 600 mg IV q.8 h.

FAMILY HISTORY: Positive for diabetes mellitus. Father had congestive heart failure and COPD. Mother had alcoholism and renal failure.

SOCIAL HISTORY: She lives with her husband. No smoking, ETOH or drug abuse.

REVIEW OF SYSTEMS: Positive for fever and chills. Positive for cough, nonproductive. No chest pain. No headache. No dizziness. No nausea, vomiting or abdominal pain. No diarrhea. No urinary frequency or urgency.

PHYSICAL EXAMINATION:
GENERAL: The patient is in no acute distress.
VITAL SIGNS: T-max of 103.6, BP 112/52, heart rate 88.
HEENT: Pupils are reactive. Conjunctivae are moist. No icterus. No conjunctival hemorrhage.
NECK: Supple. No JVD or lymph nodes palpable.
LUNGS: Occasional wheezes. No rhonchi or crackles.
HEART: S1, S2 regular. No rub, gallop or murmur.
ABDOMEN: Obese. There is no tenderness on palpation. Bowel sounds are present. There is abdominal wall cellulitis present and a foul-smelling odor beneath the abdomen.
EXTREMITIES: Chronic leg edema. Left leg with significant erythema up to the knee.
NEUROLOGIC: The patient is awake, alert and oriented x3. No focal deficits.
SKIN: No rash.

LABORATORY AND DIAGNOSTIC DATA: WBC count 22.6, hemoglobin 13.2, platelets 260. Creatinine 1.1. LFTs within normal limits. Blood cultures pending. Sputum cultures pending. Chest x-ray: No evidence of pulmonary infiltrates or effusions. Ultrasound of the right upper extremity: Limited study, no gross evidence for DVT.

ASSESSMENT: This is a (XX)-year-old female with severe obesity who was admitted with fever up to 103 and chills. Also complaining of swelling of the right arm at the area where the peripherally inserted central catheter line was in the past. Of note, the patient has significant cellulitis of the left leg and abdominal wall.

1. Fever/sepsis secondary to cellulitis of the left leg and abdominal wall cellulitis.
2. Bronchitis with no evidence of pneumonia.
3. Rule out septic thrombophlebitis.

PLAN:  The patient’s ultrasound was negative. The patient is on IV heparin, and if no further investigations will be done, heparin could be discontinued, and the patient should be continued only on subcutaneous heparin. We would continue the patient on IV clindamycin. She has allergies to penicillin and vancomycin. We would continue clindamycin for treatment of her cellulitis and sepsis. We would discontinue Avelox. Reinforce strict leg elevation.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Red, swollen, indurated area in the left side of the mandible.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who was admitted with a red, swollen, indurated area in the left side of the mandible. The patient indicated that over the years, she has had several episodes of dental-type infection with dryness and improvement after the area of tooth infection drained. The patient ended up having a mass with induration, redness, and some dryness to the outside of the jaw. She has had no severe fever or chills, but the areas are progressively getting larger and indurated, and with this clinical picture, it was first treated with antibiotics, but after the antibiotics were stopped, the problem recurred and then was finally admitted for further treatment.

PAST MEDICAL HISTORY: Indicated that she has had only hypothyroidism and hyperlipidemia. Recently, has had some elevated blood pressures, but otherwise, she has had no diabetes. No history of coronary artery disease or heart disease.

ALLERGIES: PENICILLIN.

SOCIAL HISTORY: The patient does not smoke and does not drink. No history of drug abuse.

FAMILY HISTORY: The patient has had cancer in the family. Her mother died of cancer of the esophagus, and there had been no other cancers in other members of the family.

REVIEW OF SYSTEMS: No cardiopulmonary complaints. No gastrointestinal problems. No diarrhea, nausea, vomiting, hematemesis or melena. Genitourinary was noncontributory. Osteoarticular is noncontributory.

PHYSICAL EXAMINATION: The patient is alert, oriented, and cooperative. Blood pressure is 122/80, respiratory rate is 20, heart rate is 72, and temperature is 99.2. HEENT exam shows no icterus. No petechia. Pupils are reactive to light and accommodation. Conjunctivae and sclerae are normal. The nose is normal. On examination of the mouth and oral mucosa, there is a recent surgery in the left side of the jaw for the diagnosis and treatment of her lesion. There is an area of induration in the mid portion of the left side of the mandible with an area of induration of 3 to 4 cm. There is no drainage at this time, postop, and the incisors, inflammation and some postoperative changes with bleeding. The tongue shows no lesions. The throat shows no abnormalities. The neck is supple. There is no adenopathy in the lateral or posterior cervical chains, only the inflammation in the submandibular area as mentioned in the left side. The chest is symmetric. The lungs are clear to auscultation and percussion. Heart sounds are regular rhythmic with no murmurs, gallops or rubs. The abdomen is soft. There is no visceromegaly. No masses. There are good bowel sounds. The extremities show no abnormalities. There are some osteoarthritic changes, but there are good peripheral pulses. No muscle tenderness. The neurological exam is basically within normal range.

LABORATORY DATA: Her white count was at 7400, hemoglobin was 13, hematocrit was 40, platelets normal, creatinine 0.8, and BUN 10. Chemistries were all unremarkable.

DIAGNOSTIC DATA: CAT scan of the neck showed no mass effect and no abscess and only some cellulitis. The left hemimandible showed areas of sclerosis and changes indicative of inflammation in the bone compatible with osteomyelitis. The chest x-ray did not show any other abnormalities.

ASSESSMENT: The surgical findings and the CAT scan all indicate the presence of a chronic osteomyelitis of the jaw with orocutaneous fistula that was repaired at the time of the exploration and treatment by Oral Surgery.

PLAN: We will follow the results of the cultures obtained at the time of surgery and continue the patient with Cleocin and rifampin.

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Lung mass, rule out TB.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic man with a past medical history significant for diabetes mellitus, hypertriglyceridemia, and seizure disorders. The patient also has a history of smoking but repots that he stopped smoking for the past two years. The patient developed a cough productive of yellowish sputum and was treated empirically with Levaquin for 10 days without improvement in his symptoms. The patient was further evaluated with a chest x-ray, which revealed right upper lobe density. CAT scan was obtained and demonstrated a large right upper lobe mass with central necrosis. The patient was referred to this hospital and was placed on respiratory isolation. PPD was placed to rule out tuberculosis. He was started on IV Rocephin and Zithromax, and a CT-guided biopsy was obtained. Infectious disease consult was called to evaluate the patient and assist with treatment.

PAST MEDICAL HISTORY: As mentioned above.

MEDICATIONS: The patient is currently on ceftriaxone 2 grams once a day, Zithromax 500 mg once a day, and regular insulin.

ALLERGIES: No known drug allergies.

SOCIAL HISTORY: The patient is married. He denies ETOH use and no drug use.

REVIEW OF SYSTEMS: Positive for cough and mild shortness of breath. Denies weight loss. No night sweats. No sick contacts. No chills. No headaches. No visual changes. No abdominal pain. No diarrhea. No urinary frequency or urgency.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE: No acute distress. Lying in bed and appears comfortable.
VITAL SIGNS: Temperature 100.2, BP 128/64, heart rate 118.
HEENT: Pupils are reactive. Conjunctivae are moist. No icterus. No conjunctival hemorrhage.
NECK: Supple. No JVD or lymph nodes palpable.
LUNGS: Clear to auscultation. No rhonchi or wheezes.
HEART: S1 and S2, regular. No rub, gallop or murmur.
ABDOMEN: Soft. No tenderness on palpitation. Bowel sounds present. No hepatosplenomegaly.
EXTREMITIES: There is 2+ ankle edema, more so present on the right pretibial region. No clubbing or cyanosis. Pulses are 2+.
NEUROLOGIC: The patient is awake, alert, and oriented x3. No focal deficits.

LABORATORY DATA: WBC count 10.4, hemoglobin 11.6, platelets 502. AST 76, ALT 234, and total bilirubin 0.4. Cultures and pathology reports are still pending.

ASSESSMENT AND PLAN: This is a (XX)-old-man with a history of diabetes mellitus. The patient was admitted with cough and CT scan which revealed right upper lobe mass with cavitation. The patient has a history of smoking and quit two years ago. He denies any sick contacts that would put him at high risk for tuberculosis. He also denies any travel outside of this area and no exposure to any patients with tuberculosis.

PLAN:
1. Would follow the results of his CT-guided biopsy.
2. We will continue the patient on respiratory isolation.
3. Would change the antibiotics from Rocephin and Zithromax to IV Unasyn to cover possibility of lung abscess.
4. Would also obtain ultrasound of both legs due to edema that was noted on the physical exam to rule out deep venous thrombosis as well.
5. Will follow the patient with you and assist with treatment.

REFERRING PHYSICIAN:  John Doe, MD

REASON FOR CONSULTATION:  A patient with stump pain and fever following above-knee amputation.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old Hispanic male with history of non-insulin-dependent diabetes mellitus and history of left great toe amputation, who developed osteomyelitis of the left foot requiring left below-the-knee amputation approximately 20 months ago. The patient developed a wound over the left below-the-knee amputation stump approximately four or five weeks ago. He started having drainage and increasing pain. The patient was brought to the emergency room. He was seen by Dr. Jane Doe, and he underwent left above-the-knee amputation for nonhealing amputation of left below-the-knee amputation stump secondary to osteomyelitis. The patient’s blood cultures revealed Staphylococcus aureus. He was recently discharged from the hospital. He developed candiduria. He also had presumptive pneumonia. The patient was discharged on ciprofloxacin as well. The patient is now readmitted with a three-day history of subjective fever. His temperature was 102.5, but he was defervesced since admission. His chief complaint appears to be left stump pain, but he denies any sore throat, rhinorrhea, earaches, cough, chest pain. No shortness of breath, no nausea, vomiting, or diarrhea. No urinary symptomatology, including dysuria, polyuria or urinary urgency. No hematuria. No myalgias or arthralgias. The patient’s WBC is actually within normal limits, and the patient just had one temperature on admission, and he has been afebrile seen then.

PAST MEDICAL HISTORY:  Significant for left below-the-knee amputation 20 months ago, left great toe amputation for diagnosis of osteomyelitis of the left foot. The patient is status post above-the-knee amputation of the left lower limb because of nonhealing amputation as well as osteomyelitis.

CURRENT MEDICATIONS:  Include Glucophage, Avandia, Vasotec, and Lortab. He was also taking Cipro, and he ran out of Diflucan on Thursday.

ALLERGIES:  NKDA.

FAMILY HISTORY:  Unremarkable.

SOCIAL HISTORY:  No history of alcohol abuse or smoking.

REVIEW OF SYSTEMS:  The patient denies any hearing loss, photophobia, blurred vision, denies any sore throat. No dysphasia. No aphasia. No nausea, vomiting, diarrhea, constipation, hematemesis or hematochezia. He denies any dysuria or polyuria. He denies hematuria. No chest pain, shortness of breath, PND or orthopnea. No hemoptysis. No myalgias or arthralgias, but he does have pain of his stump. No history of blood dyscrasia or bleeding disorder.

PHYSICAL EXAMINATION:
VITAL SIGNS:  T-max 102.5; now, it is 98.6; pulse 64; respiratory rate 20; and blood pressure 94/64.
GENERAL:  The patient is a well-developed, well-nourished Hispanic male, in no acute distress.
HEENT:  Pupils are equal and reactive to light. Extraocular muscles are intact. Oropharynx, no evidence of oral thrush.
NECK:  Supple. No thyromegaly. Trachea midline.
LUNGS:  Clear to auscultation and percussion. No wheeze, rhonchi or wheezing.
HEART:  Normal rate and rhythm, normal S1, S2. No murmur, gallop, rub, thrills or heaves.
ABDOMEN:  Soft, no rigidity, guarding or rebound. No hepatosplenomegaly. Positive bowel sounds.
EXTREMITIES:  Show left below-the-knee amputation stump, tender to palpation. At this time, it does not have any redness, wound separation or drainage.
SKIN:  The skin temperature appears normal. Skin has no evidence of rash.
LYMPHATICS:  Reveal no palpable cervical or axillary lymphadenopathy.

LABORATORY DATA:  WBC is 5.2, hemoglobin 10.8, and platelet count 284.

IMPRESSION:
1.  Fever. Considerations are:
a.  Fungemia.
b.  Pulmonary, rule out pneumonia.
c.  Urinary tract infection.
d.  Secondary to stump hematoma versus abscess, evaluate if drug related.
2.  Status post above-the-knee amputation of left lower limb for nonhealing amputation and osteomyelitis.
3.  Non-insulin-dependent diabetes mellitus.
4.  Status post below-the-knee amputation 20 months ago.
5.  Status post fall approximately one week prior to his recent hospitalization.
6.  History of chronic osteomyelitis of the left foot.
7.  Status post amputation of the left great toe.
8.  History of hypertension.

The patient recently was diagnosed with osteomyelitis, nonhealing amputation left below-the-knee, for which he required above-the-knee amputation of the left lower limb. Cultures grew Staphylococcus aureus. He had postoperative fever. He was discharged home on Cipro for possible pneumonia as well as Diflucan for candiduria. He now presents with three-day history of fever. No clear etiology other than this significant pain over the stump. Therefore, need to rule out abscess versus infected hematoma. He has defervesced, and his white count is within normal limits. He does not appear septic or toxic. Therefore, we will not reinitiate antibiotics until further workup, including blood, urine cultures, and MRI of the left above-the-knee amputation stump.

RECOMMENDATIONS:
1.  We agree with MRI of the left above-the-knee amputation stump.
2.  Blood cultures sent for culture and sensitivity.
3.  UA, C and S.
4.  Follow CBC with differential.
5.  Chest x-ray.
6.  Hold antibiotics for now depending on above evaluation.