DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION:
Evaluation and management of rash.
HISTORY OF PRESENT ILLNESS:
Thank you for this infectious disease consult. The patient is a (XX)-year-old female who had a bout of pharyngitis about 5 weeks prior to admission. The pharyngitis appeared to persist, was given a dose of Biaxin which did not seem to help her too much. Later on, the patient started developing what appeared to be another type of pharyngeal reaction and possible recurrent infection. The patient was also given a course of antibiotics which consisted of Cipro. The patient then started noticing a nodular lesion occurring mostly over the hands and upper extremities bilaterally, as well as some involvement of both knees. This was accompanied by some slight arthralgias and also a complaint of swollen left toe along with increasing tenderness over one of the plantar areas of the foot. The patient did not have any noticeable fevers that were documented; however, did feel hot and continued to complain of some night sweats which has been ongoing, and at this point, still remains diaphoretic. Also has had some weight loss over the last few weeks or so with a poor appetite secondary to pharyngitis. The sore throat has resolved actually to a large degree at this time. No other symptoms. No diarrhea. No nausea. No vomiting. Did not have any chest pain or shortness of breath. No other HEENT symptoms other than the pharyngitis mentioned above. Full 10 points reviewed with the patient are negative other than as mentioned above.
PAST MEDICAL HISTORY:
Otherwise, unremarkable. Does have some mild hypertension and anxiety.
MEDICATIONS:
Medication list has been reviewed. Has been on Effexor and lisinopril, more recently on the antibiotics mentioned above. Was given a dose of vancomycin in the ED.
ALLERGIES:
No known allergies.
SOCIAL HISTORY:
Does not use any tobacco, alcohol or drugs. No recent travel abroad. The patient does not have any pets at home. No recent camping. Does not have HIV risk factors. No history of injection drug use.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert and oriented, in no acute distress. Does appear anxious and is diaphoretic.
VITAL SIGNS: Temperature 97.6, blood pressure 136/78, respirations 21, heart rate 80.
HEENT: Normal. Normocephalic and atraumatic. Pupils are equal and reactive. Oropharynx is clear without any lesions. There is no thrush.
NECK: Supple without lymphadenopathy.
HEART: Regular rate and rhythm without any murmurs.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, nondistended. The inguinal area is normal.
EXTREMITIES: Lower extremities are without cyanosis, clubbing or edema.
SKIN: Examination shows a torso and back that is free of any lesions. However, the upper extremities bilaterally from the hand to halfway up the forearm does reveal areas of scattered nodules with central umbilical depression. The central area appears to be slightly necrotic or possibly having some sort of small eschar. There are probably about dozen or so nodules bilaterally on the upper extremities. The lower extremity nodules are a little bit more diffuse and are less present, but they appear in small areas over the knees bilaterally. Over the lower extremity, plantar area of the left foot, there is a slightly erythematous nodule that is over the plantar aspect and slightly tender to palpation. This is right below the first metatarsal of the left foot. Skin is quite warm and moist.
NEUROLOGIC: Grossly nonfocal.
LABORATORY DATA:
White count was initially elevated with a white count of 14.4. It was predominantly neutrophilic. Currently, the white count is normal. Sed rate is extremely high at 106. UA is normal. Blood cultures have been drawn and are negative. ASO titers are negative.
IMPRESSION:
1. Acute pharyngitis.
2. Multiple nodule lesions with central umbilication and eschar, which resemble erythema nodosum.
3. Elevated sed rate.
MEDICAL DECISION MAKING:
The differential is still broad in this case and it is difficult to make a determination just based on morphology alone. The differential remains broad and includes bacterial pathogens, fungal and viral pathogens. Extensive orders have been written and include Bartonella, Chlamydia, Mycoplasma, staphylococci, crypto, blasto, histo, CMV and EBV among others. Probably, we will not be able to get a diagnosis through serology alone and a biopsy will be necessary.
RECOMMENDATIONS:
1. We would check HIV status. We will also check a viral load in case this is an acute HIV syndrome.
2. We will check the RPR.
3. Chlamydia titers.
4. Histo, cocci, blasto and cryptococcal titers. All the orders have been written.
5. We will start the patient on doxycycline IV.
6. The patient needs a dermatology evaluation.
Thank you, Dr. Doe, for allowing me to participate in this patient’s care. We will follow along with you.
Infectious Disease Consult Sample #2
DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
CONSULTANT: Jane Doe, MD
REASON FOR CONSULTATION: Evaluation and management of leukocytosis.
Thank you for this infectious disease consult.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male. Limited history was obtained from an interpreter as well as from the chart. The patient was admitted for chest pain. Workup included a CT of the chest, which suggested a possible aortic aneurysm, but apparently that was found not to be the case. However, his hospitalization has been complicated by a number of factors including acute renal failure and possible GI bleed. He had an EGD done, which showed gastric ulcerations but no other major GI bleed. He also was intubated for a time for respiratory distress, had pleural effusions tapped as well as bronchoscopy, which did not grow any organisms. This patient’s white count has remained in the high teens, but over the last 2 or 3 days, the patient’s abdomen has been slightly more distended and more painful. He also had a white count spike up to the 20s, and because of that, infectious disease consultation was requested. Most recent abdominal films done showed contrast all the way to the rectum, so there was no complete bowel obstruction, but the possibility of a partial obstruction or abscess has not been excluded. The patient tells me right now that he is having abdominal pain, mostly epigastric, some down in the lower abdomen. He is not having any bowel movements. No diarrhea. He does have some occasional shortness of breath and dyspnea on exertion. Also has some leg pain. Otherwise, he does not have any fevers, chills, night sweats or other constitutional symptoms. No other GI symptoms. No GU symptoms.
REVIEW OF SYSTEMS: The full 14 points were reviewed with the patient and are otherwise negative.
PAST MEDICAL HISTORY: Significant for hypertension, asthma, history of bronchitis, some heart disease including left ventricular hypertrophy.
PAST SURGICAL HISTORY: Cardiac catheterizations.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient is an ex-smoker. He does not use alcohol or drugs. Currently retired.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION:
GENERAL: The patient is alert, oriented, looked comfortable for the most part.
VITAL SIGNS: He has never had a fever so far in this hospitalization, and over the last 24 hours, his T-max has been 98.5. Currently, his pulse is 88, respirations 21, and blood pressure 126/78.
HEENT: Pupils are equal and reactive. Sinuses are nontender. The oropharynx reveals a lot of saliva. The tongue appears discolored. There are no teeth in place.
NECK: Supple without lymphadenopathy.
HEART: Regular rate and rhythm.
LUNGS: Reveal diminished breath sounds at the bases; otherwise, there are no wheezes heard.
ABDOMEN: Distended and there is some guarding as well. It is tender to palpation. The inguinal area is normal. Foley catheter is in place.
EXTREMITIES: Without cyanosis, clubbing or edema.
SKIN: Intact.
NEUROLOGIC: Appears nonfocal.
LABORATORY AND DIAGNOSTIC DATA: Reviewed. Does show a white count that is increasing at 27.4. No left shift is noted, 9% bands seen. Creatinine is worsening at 3.8. The urinalysis was dirty with white cells, but no bacteria and no growth from that. Urine culture was noted. He does not have any positive blood cultures. Other laboratory data have been reviewed.
Chest x-ray does show small pleural effusion and atelectasis. No discrete infiltrate was noted.
IMPRESSION:
1. Abdominal distention.
2. Leukocytosis.
3. Pleural effusion.
4. Gastric ulcers.
DISCUSSION AND MEDICAL DECISION MAKING: The patient’s main symptoms are abdominal, and given his leukocytosis as well as increasing abdominal pain, we need to rule out intra-abdominal pathology. I am concerned about a possible abscess.
RECOMMENDATIONS:
1. I would like to get a CT of the abdomen and pelvis with oral contrast. Probably, would need to withhold IV contrast given his renal failure.
2. We will recheck amylase and lipase.
3. I will broaden his antibiotics and treat with Zosyn. I will discontinue Cipro and Flagyl and then change it to Zosyn. I will follow with you.
Thank you for allowing me to participate in this patient’s care.
