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Infectious Disease Medical Transcription Consult Sample

DATE OF CONSULTATION: MM/DD/YYYY

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.


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