SUTTER COAST HOSPITAL
EXAMPLE - CONSULTATION, Gregory J. Duncan, M.D.
[DATE OF CONSULTATION automatically added by iTran]
REFERRING PHYSICIAN:
DATE OF ADMISSION:
Matthew C. Blundell, M.D.
03/20/2007
REASON FOR CONSULTATION:
Infection left leg.
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
inmate who was recently admitted to Sutter Coast Hospital
with several areas of infection, primarily in the left
buttock and lower extremity. He states that he was "taken
down" by a correctional officer at Pelican Bay Prison about
10 days ago and subsequently developed some sites of
infection, which the patient states were culture positive
for MRSA.
The patient was admitted through the emergency department
and incision and drainage of the left upper thigh and left
knee areas was performed and cultures were obtained.
The patient states he has been improving gradually during
the hospitalization, but still has some pain in the left
knee and left posterior thigh area.
PAST MEDICAL HISTORY - MEDICAL ILLNESSES:
1. Hepatitis C.
2. Hypothyroidism.
3. Hyperlipidemia.
4. Gastroesophageal reflux disease.
5. Psychiatric disorder.
ALLERGIES: From review of the patient's chart, notable for
a PENICILLIN allergy, but the patient states today he has
no problems taking penicillin and that that is an error
that the allergy was listed.
MEDICATIONS: At the time of admission omeprazole, Lipitor,
thyroid replacement, Septra DS, ibuprofen, Paxil, and
Seroquel.
SOCIAL HISTORY: The patient is incarcerated at Pelican Bay
Prison and is currently not using any tobacco or alcohol.
PHYSICAL EXAMINATION:
GENERAL: Patient is an alert male in no distress, answers
questions appropriately, and appears comfortable.
HEAD: Normocephalic, atraumatic.
NECK: Rotation is pain free.
CHEST: Clear.
CARDIAC: Rate and rhythm regular.
ABDOMEN: Soft, nontender, and nondistended with no rebound
or guarding.
EXTREMITIES: Several areas of infection, primarily the
left posterior proximal thigh and left knee, where there is
some redness and swelling with incisions in both areas
notable for some serosanguineous drainage; also a small
nodular lesion which may represent a very small abscess
over the left elbow region. Several macular lesions on the
patient's back and some on the right lower extremities
which do not appear abscesses, but may represent some tiny
foci of infection, possibly from disseminated sepsis.
Motor and sensory status normal in the lower extremities.
Pulses are 1+ at the foot and ankle. Asymmetry of
swelling, 1+ in the right lower extremity and 2+ and left
lower extremity distal to the knee. No irritability and no
effusion in the left knee. The area of drainage and
redness is distal to the knee joint and somewhat distal to
the insertion of the extensor mechanism on the anterior
aspect of the lower leg.
DIAGNOSTIC STUDIES: X-ray of the left knee was negative by
report for any evidence of osteomyelitis. Today's CBC
notable for a white blood cell count of 14,000, hematocrit
33%, differential WBC notable for 83% neutrophils, 9%
lymphocytes. CBC on admission notable for white blood cell
count of 16,800. Glucose has been elevated between 138 and
146 over the last three draws. Albumin was notably low,
2.3 today and 2.7 yesterday. Alkaline phos elevated at 304
today and 286 on yesterday’s draw with mild elevation of
total bilirubin. Blood cultures are negative at one day.
Left lower leg and left upper thigh cultures show 4+ grampositive cocci.
IMPRESSION:
1. Multiple abscesses.
2. Rule out septic arthritis left knee.
3. Hepatitis C.
4. Protein malnutrition.
5. Elevated liver function tests.
RECOMMENDATION: The primary concern prompting consultation
was that of possible septic arthritis in the knee.
Clinically this does not appear to be the case, but I would
recommend an aspiration to obtain synovial fluid for
cultures and analysis if sufficient fluid is present. The
patient elected to proceed and the left knee was aspirated,
yielding only 2 cc of normal-appearing synovial fluid which
was sent for culture and sensitivity.
With respect to the area of swelling in the left lower
extremity, the situation was discussed with Dr. Schommer.
There may be further consolidation of the infection
necessitating a longer incision and surgical drainage.
Currently there is no know loculation or fluctuance on
clinical exam but, often as the infection consolidates,
additional abscess formation occurs and surgical
debridement of the infected soft tissues is necessary.
The patient is also undergoing a cardiac workup for
valvular infection.
I would recommend an ultrasound of the left lower extremity
to rule out DVT.
The patient is currently on vancomycin pending culture
results to cover for the strong possibility of MRSA.
The patient also has evidence of chronic malnutrition and
likely has chronic anemia which increases his
susceptibility to infection.
From an orthopedic standpoint there is no current
indication for drainage of the knee joint, but I will
follow up with culture results as they become available.
If there is a positive culture from the knee, then
arthroscopic or open incision and drainage of the knee
joint itself will be necessary. Dr. Schommer is following
the soft tissue infections elsewhere in the extremities.