Pneumonia Consultation Transcription Sample Report
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.
