DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
ATTENDING PHYSICIAN: John Doe, MD
DISCHARGE DIAGNOSES:
1. Enterococcus faecalis urosepsis.
2. Enterococcus faecalis bacteremia.
3. Methicillin-susceptible Staphylococcus aureus bacteremia.
4. Prosthetic aortic valve replacement with filamentous structure, possible infective endocarditis.
5. Anemia secondary to sepsis.
6. Bilateral nephrolithiasis with left ureteral stent.
7. History of colon cancer, status post resection of sigmoid colon.
DISCHARGE MEDICATIONS:
1. Gentamicin 100 mg IV daily for 7 days.
2. Unasyn 3 grams IV q. 6 hours for 7 days
3. Altace 2.5 mg daily.
4. Protonix 40 mg a day.
CONSULTATIONS OBTAINED DURING THIS ADMISSION:
1. Infectious diseases service.
2. Urology service.
3. Cardiology service.
4. Hematology service.
DIAGNOSTIC STUDIES COMPLETED DURING THIS ADMISSION:
1. Change of left ureteral stent.
2. Transesophageal echocardiogram, which revealed a nonspecific filamentous structure of the prosthetic aortic valve consistent most likely with scar tissue; however, infective endocarditis cannot be ruled out.
3. PICC line insertion of the right arm.
HOSPITAL COURSE: The patient is a (XX)-year-old Hispanic male with a history of colon cancer, recently resected, and bilateral nephrolithiasis as well as a prosthetic aortic valve replacement, who presented to the emergency room with fever, chills, and failure to thrive.
Of note, he was recently seen in the emergency room, approximately 2 days prior to admission, for the same symptoms and discharged home for presumed viral syndrome. Nonetheless, when the patient presented to the ER, he was found to be febrile with a white blood cell count of 4500, hemoglobin of 10.8, and hematocrit of 32. He had an albumin of 3.1, a total protein of 6.2, alkaline phosphatase of 62, SGPT of 8, BUN of 18, total bilirubin of 0.8, calcium of 8.5, CO2 of 27, chloride of 102, creatinine of 1, potassium of 4.2, SGOT of 25, sodium of 137, and glucose of 114. His troponin I was less than 0.010. The patient had blood cultures obtained, and he was on empiric antibiotics.
The patient was transported from the emergency room where he was maintained on IV antibiotics. Of note, at the time of his presentation, the patient’s urinalysis revealed large blood with positive nitrites, moderate leukocyte esterase, 368 wbc’s per high power field and more than 44,000 rbc’s per high power field. His blood cultures, which were obtained on MM/DD/YYYY, ultimately became positive on MM/DD/YYYY. They grew out Enterococcus faecalis for two sets and one set grew out methicillin-susceptible Staphylococcus aureus. Because his urine culture also grew out Enterococcus faecalis, the patient had his ureteral stent on the left changed. The patient ultimately defervesced and continued to do well clinically.
Of note, he had a transesophageal echocardiogram performed on MM/DD/YYYY, the results of which are discussed above to make sure that the prosthetic aortic valve is not infected. The patient was ultimately tolerating solids and liquids well and had a PICC line placed for the ability to give long-term antibiotics.
At the time of his discharge, his albumin was 2.7, glucose was 176, total protein was 6.6, BUN was 12, creatinine was 1, sodium was 136, potassium was 4.1, chloride was 101, CO2 was 28, calcium was 8.4, SGOT was 12, and SGPT was 6.
Of note, he had a normal T4-T3 circulating and a normal TSH. His ferritin was 126. Vitamin B12 was 346. He had normal serum protein electrophoresis, and his sedimentation rate at the time of discharge was 113. Also, at the time of discharge, his white blood cell count was 7200, hemoglobin 9.6, hematocrit 29.6, and platelets were 324,000.
The patient was transferred to the care of outside hospital where he will receive 7 days of gentamicin and 7 days of Unasyn. His son was instructed to report right back to the hospital should he develop any signs of fever, chills or night sweats.
