DATE OF CONSULTATION: MM/DD/YYYY
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.
