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Infectious Disease Consultation Medical Transcription Sample Report

DATE OF CONSULTATION:  MM/DD/YYYY

REFERRING PHYSICIAN:  John Doe, MD

CONSULTANT:  Jane Doe, MD

REASON FOR CONSULTATION:  Evaluation and management of leukocytosis.

Thank you for this infectious disease consultation. 

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male.  Limited history was obtained from an interpreter as well as from the chart.  The patient was admitted for chest pain.  Workup included a CT of the chest, which suggested a possible aortic aneurysm, but apparently that was found not to be the case.  However, his hospitalization has been complicated by a number of factors including acute renal failure and possible GI bleed.  He had an EGD done, which showed gastric ulcerations but no other major GI bleed.  He also was intubated for a time for respiratory distress, had pleural effusions tapped as well as bronchoscopy, which did not grow any organisms. This patient's white count has remained in the high teens, but over the last 2 or 3 days, the patient's abdomen has been slightly more distended and more painful.  He also had a white count spike up to the 20s, and because of that, infectious disease consultation was requested.  Most recent abdominal films done showed contrast all the way to the rectum, so there was no complete bowel obstruction, but the possibility of a partial obstruction or abscess has not been excluded. The patient tells me right now that he is having abdominal pain, mostly epigastric, some down in the lower abdomen.  He is not having any bowel movements.  No diarrhea.  He does have some occasional shortness of breath and dyspnea on exertion.  Also has some leg pain.  Otherwise, he does not have any fevers, chills, night sweats or other constitutional symptoms.  No other GI symptoms.  No GU symptoms.

REVIEW OF SYSTEMS:  The full 14 points were reviewed with the patient and are otherwise negative.

PAST MEDICAL HISTORY:  Significant for hypertension, asthma, history of bronchitis, some heart disease including left ventricular hypertrophy.

PAST SURGICAL HISTORY:  Cardiac catheterizations.

ALLERGIES:  NO KNOWN DRUG ALLERGIES.

SOCIAL HISTORY:  The patient is an ex-smoker.  He does not use alcohol or drugs.  Currently retired.

FAMILY HISTORY:  Noncontributory.

PHYSICAL EXAMINATION:
GENERAL:  The patient is alert, oriented, looked comfortable for the most part.
VITAL SIGNS:  He has never had a fever so far in this hospitalization, and over the last 24 hours, his T-max has been 98.5.  Currently, his pulse is 88, respirations 21, and blood pressure 126/78.
HEENT:  Pupils are equal and reactive.  Sinuses are nontender.  The oropharynx reveals a lot of saliva.  The tongue appears discolored.  There are no teeth in place.
NECK:  Supple without lymphadenopathy.
HEART:  Regular rate and rhythm.
LUNGS:  Reveal diminished breath sounds at the bases; otherwise, there are no wheezes heard.
ABDOMEN:  Distended and there is some guarding as well.  It is tender to palpation.  The inguinal area is normal.  Foley catheter is in place.
EXTREMITIES:  Without cyanosis, clubbing or edema.
SKIN:  Intact.
NEUROLOGIC:  Appears nonfocal.

LABORATORY AND DIAGNOSTIC DATA:  Reviewed.  Does show a white count that is increasing at 27.4.  No left shift is noted, 9% bands seen.  Creatinine is worsening at 3.8.  The urinalysis was dirty with white cells, but no bacteria and no growth from that.  Urine culture was noted.  He does not have any positive blood cultures.  Other laboratory data have been reviewed.

Chest x-ray does show small pleural effusion and atelectasis.  No discrete infiltrate was noted.

IMPRESSION:
1.  Abdominal distention.
2.  Leukocytosis.
3.  Pleural effusion.
4.  Gastric ulcers.

DISCUSSION AND MEDICAL DECISION MAKING:  The patient's main symptoms are abdominal, and given his leukocytosis as well as increasing abdominal pain, we need to rule out intra-abdominal pathology.  I am concerned about a possible abscess.

RECOMMENDATIONS:
1.  I would like to get a CT of the abdomen and pelvis with oral contrast.  Probably, would need to withhold IV contrast given his renal failure.
2.  We will recheck amylase and lipase.
3.  I will broaden his antibiotics and treat with Zosyn.  I will discontinue Cipro and Flagyl and then change it to Zosyn.  I will follow with you.

Thank you for allowing me to participate in this patient's care.