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Infectious Disease (ID) Consultation Medical Transcription Sample Report



REASON FOR CONSULTATION:  Abscess in the left upper chest.

HISTORY OF PRESENT ILLNESS:  The patient is a pleasant (XX)-year-old woman who reportedly has prior history of right upper extremity DVT. She states that she presented to the hospital emergency department because of problems with pain and swelling in the left axillary area and left lateral adjacent chest; also, apparently, was having pain in the back. The patient reports that about a week or so prior to that, she developed a small lesion in the right axilla, contralateral side, which appeared to be consistent with a boil. She states that there was spontaneous drainage from this and the area seemed to be healing. Then, about 3 or 4 days before admission, she developed a similar abnormality in the left axillary area, on the anterior wall of the axilla, which continued to enlarge and become painful. She states that she actually was unable to move the shoulder because of the pain. She had pain towards the back of the shoulder and also in the anterior chest laterally and, apparently, in the lateral prepectoral area. She actually had spontaneous drainage of purulent material at home. She was having some feverishness at home as well.

She presented to the emergency department. At that time, initial temperature was 98.6, pulse 66, blood pressure 134/90, and O2 saturation 99%. She did have cultures taken, which were positive for polymicrobial growth, currently consisting of Enterococcus faecalis, Serratia marcescens, and Proteus species. Enterococcus was susceptible to ampicillin, penicillin and vancomycin. The Serratia was susceptible to aztreonam, ceftazidime, cefepime, Cipro, ceftriaxone, cefotetan, ertapenem, gentamicin, imipenem, Septra and resistant to cefazolin. Proteus susceptibilities are reportedly pending at this time. The patient has been on antibiotics including Zosyn and vancomycin. She underwent evaluation by Dr. Bradford Doe and was taken to surgery, undergoing incision and drainage and possibly biopsy as well of the left axillary abscess. Pathology is reportedly pending at this time. Infectious Disease consultation is requested today for assistance with evaluation and management.

PAST MEDICAL HISTORY:  Reportedly positive for right upper extremity DVT about 5 years ago, for which the patient does continue on chronic anticoagulation with Coumadin. She has had previous cesarean section x2 reportedly. She is not aware of any history of any prior skin and soft tissue infections other than the recent lesions as described above. She does occasionally develop some similar lesions in the axilla, but none of which had ever resulted in any major problems.

MEDICATIONS:  Reportedly are stated as Coumadin, Lovenox, Zosyn 3.375 grams IV q.6 h., and vancomycin 1 gram IV q.24 h.

SOCIAL HISTORY:  The patient states that she lives with her mother, a brother and sister, and the patient has 2 children who all live at home with her. She is a cigarette smoker, usually smoking about 2 packs of cigarettes about every 3 to 4 days. She reports only occasional use of alcohol. She denied any utilization of any illicit drugs and also denied any utilization of any injectable drugs.

FAMILY HISTORY:  Positive for diabetes.

REVIEW OF SYSTEMS:  The patient denied any known trauma to the left axilla or chest wall area. No animal bites or scratches. She has no history of stroke or seizure disorder. No dysphagia. No history of thyroid disease or goiter. No history of diabetes mellitus. No history of myocardial infarction or rheumatic heart disease. No history of asthma or emphysema. No history of tuberculosis. No abdominal pain. No vomiting. No diarrhea. No dysuria or hematuria. No personal history of cancer. No severe arthralgia or myalgia at this time.

VITAL SIGNS:  Temperature 97.6, pulse 74, and blood pressure 139/91. The patient has been afebrile in the hospital with the exception of a temperature of 99.6 degrees at midnight.
GENERAL:  The patient is overweight. She is awake and alert and in no acute distress at this time.
HEENT:  Pupils are round and reactive. Sclerae anicteric. Conjunctivae noninjected. Oral mucosa moist. No thrush. No pharyngitis.
NECK:  Supple. Trachea midline. No palpable thyromegaly. No frank cervical or supraclavicular adenopathy.
CHEST:  Symmetrical excursion. Lungs are clear to auscultation without wheezes.
HEART: Regular rate and rhythm without rub.
ABDOMEN:  Nondistended. Normoactive bowel sounds. No guarding or rebound tenderness. No palpable hepatomegaly.
EXTREMITIES:  No clubbing or cyanosis. No palpable cords. No calf tenderness to palpation. In the left upper extremity, the patient has surgical dressing in the axilla. There is still some induration palpable and some serosanguineous drainage noted on the dressing. Previously, the patient had edema around the anterior wall of the axilla in the lateral prepectoral area, but that appears to be improving now. She also is having some improving range of motion of the shoulder. No crepitance is evident. No foul odor.
SKIN:  Otherwise, without diffuse rash. No vesicles or bullae. No Janeway lesion or Osler nodes.

LABORATORY DATA:  White blood count on day of admission to the emergency department was 15,500. Three days prior to admission, it was 18,500. Hemoglobin on day of admission was 11.3. PT 18.4 and INR 1.50 today. Sodium on day of admission to the emergency department was 133, creatinine 0.9 and BUN 6. Pregnancy screen was negative. Troponin less than 0.02. CPK 38.

Chest x-ray reportedly showed no acute pulmonary infiltrates.

1.  The patient is status post surgical incision and drainage of left axillary abscess.
2.  Previous wound cultures, as described above, with polymicrobial growth. Of note, surgical wound cultures showing progress at this time and no growth so far.
3.  The patient is overweight.
4.  Leukocytosis.
5.  History of right upper extremity deep venous thrombosis approximately 5 years ago.
6.  Cesarean section x2.
7.  Tobacco abuse.

RECOMMENDATIONS:  We will follow up pending surgical cultures with regards to antibiotic coverage. We will continue for now on IV Zosyn. We will go ahead and discontinue vancomycin at this time. No resistant gram-positives have been identified. We will await Proteus susceptibilities. Hopefully, further adjust antibiotics when additional culture information is available. Also, we will recheck the patient's CBC in a.m.

Thank you very much for allowing me to participate in the care of your patient.

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