DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Bacteremia.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old female seen at the request of Dr. John Doe for further evaluation of bacteremia. The patient is interviewed in conjunction with her husband, who is at the bedside. The patient’s history is pertinent for hydrocephalus dating back to approximately 10 years ago. She had VP shunt placed at that time and subsequently had revisions of her VP shunts multiple times thereafter due to obstruction of the shunt from choroid plexus fluid cells. The patient’s acute problem began with onset of headache. She also had some problems with nausea and vomiting, and by her husband’s report, this was a rather abrupt onset. As a result of this acute event, she was seen at an outside facility and subsequently transferred here.
The patient’s hospital course has been pertinent for having undergone revision of the VP shunt, having evidence of intraventricular hemorrhage, which has required a left frontal ventriculostomy. She has received cefazolin in the perioperative time frame and initially had some low-grade temperatures. Her temperature began to accelerate approximately 3 days ago. Blood cultures obtained 2 days ago have now returned 1 or 2 showing Gram-negative rods. As a result of the positive blood cultures, Infectious Disease consultation has been requested.
In discussion with the patient’s husband and nurse, there has not been significant amount of cough or sputum production. She did require intubation-assisted ventilatory support. Her husband reports that she has had some complaints of some discomfort near the PICC line site. There has been no significant vomiting over the last several days. She may have had one episode of emesis shortly after admission. The patient denies any abdominal pain or abdominal discomfort. There is no background history for significant infection such as pyelonephritis, kidney infections, urinary tract infections, pneumonias or sinus disease. The only antibiotic that she has required was perioperative antibiotic for cesarean section 11 months ago; otherwise, she does not have significant infection-related problems or need for antibiotics.
PAST MEDICAL HISTORY: Hydrocephalus requiring VP shunt and 4 revisions and cesarean section.
SOCIAL HISTORY: There is no alcohol or tobacco abuse.
FAMILY HISTORY: No significant medical problems according to the husband.
ALLERGIES: DILANTIN. NO ANTIBIOTIC ALLERGIES.
REVIEW OF SYSTEMS: The patient has not had history for seizures. There is no glaucoma, cataracts, hearing imbalance or nasal sinus complaints. No acid reflux, peptic ulcer disease, hepatitis, gallbladder disease or diverticulitis. No asthma, bronchitis, pneumonias, tuberculosis, hypertension, rheumatic fever or heart disease. No diabetes, thyroid disorders. No history for phlebitis. No kidney stone history.
PHYSICAL EXAMINATION:
VITAL SIGNS: At present, temperature is 100.4 degrees, blood pressure 106/50, pulse 94, and respirations 20.
GENERAL: The patient is an awake female with a flat affect who has a left ventriculostomy tube in place.
HEENT: Mouth and Throat: Limited visualization, no gross exudates or erythema. No scleral icterus, conjunctivae or petechiae.
NECK: No palpable masses or tenderness.
CHEST: Exam shows symmetrical excursion. No focal wheezes or rales. No tubular breath sounds.
HEART: Reveals rhythmic heart sounds, normal S1 and S2. No significant rub or gallop.
ABDOMEN: Flat, old healed incision from previous VP shunt. By palpation, there is no hepatosplenomegaly, rebound, guarding or tenderness. The kidneys are nontender to palpation or percussion. There are no other masses or tenderness.
EXTREMITIES: Lower extremities reveal palpable pedal pulses. No pedal edema. The patient has a PICC line in the right upper extremity, she currently denies any pain and does not show any gross drainage at the insertion site.
SKIN: Skin does not show acute rashes or inflammation.
NEUROLOGIC: Neurologically, she has a flat affect. She has relatively good grip strength. She is right-handed.
LABORATORY DATA: White count 7800, hemoglobin 12.4, and platelet count 372,000. Sodium 136, potassium 3.4, chloride 106, bicarbonate 24, BUN 6, and creatinine 0.5. CSF fluid showed 27 nucleated cells, 39,600 red cells, 10% polys, 38% lymphocytes, 1% monocytes, 27% eosinophils, 24% macrophage. Glucose 68. Protein 278. Gram-stain shows rare wbc’s, no organism seen. Blood cultures from 2 days ago, 1 of 2 shows Gram-negative rods. Urine culture from 2 days ago, no growth. Urinalysis from 2 days ago, unrevealing. Cerebrospinal fluid from 3 days ago, no growth.
DIAGNOSTIC DATA: Chest x-ray from last week did not show any focal infiltrates. CT of the brain from yesterday showed some decrease in the amount of blood within the lateral and third ventricles. There is some interval increase in the size of the lateral one-third ventricles at the level of the aqueduct and some persistent low attenuation infarct/edema in the posterior right parietal white matter. CSF culture from today showed no growth at 5 hours.
IMPRESSION:
1. Gram-negative bacteremia. Considerations include line versus occult genitourinary versus pulmonary versus central nervous system (doubt).
2. Status post revision of ventriculoperitoneal shunt for hydrocephalus.
3. Intraventricular hemorrhage with obstructive hydrocephalus requiring left frontal ventriculostomy.
4. History for multiple ventriculoperitoneal shunts.
5. No known allergies with the exception of Dilantin.
6. History of cesarean section.
In summary, this patient is status post revision of the proximal shunt system with ventricular catheter, valve and placement of a left frontal ventriculostomy. Has developed an accelerated febrile state with positive blood culture for Gram-negative rods. Currently, we plan to begin meropenem and tobramycin with discontinuation of cefazolin. Based upon further culture information as available, further recommendations will follow. Current plan of recommendations, including exchange of PICC line, has been discussed with the patient at bedside, with husband in attendance, and reviewed with the nurse as well as Dr. John Doe.
RECOMMENDATIONS:
1. Discontinuation of cefazolin.
2. Discontinue PICC line with culture of PICC line tip.
3. Followup blood cultures as ordered.
4. Followup pending cultures with adjustment of antibiotic therapy based upon further defined database.
5. Begin meropenem 1 g IV q. 8 h.
6. Tobramycin 320 mg IV x1.
7. Random tobramycin level 12 hours after dose.
8. Based upon further database, additional recommendations to follow.
