DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Positive urine culture.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old gentleman. He has a history of hypertension and Parkinson’s disease as well as history of bladder cancer. The patient has a continent urostomy for which he performs self-catheterization approximately every q.4-6 hours. The patient reports that he has actually been feeling poorly for at least a month now. According to the wife, he has been having low-grade temperatures, sometime as high as 100.5 degrees. He also has some problems with fatigue and some degree of shortness of breath.
The patient does state that he was placed on antibiotics consisting of Levaquin, finishing this up about 3 weeks ago, for a urinary tract infection. He thinks possibly with E. coli, but he could not remember if that was actually an older culture. The patient thought that he might have had some slight improvement while on the Levaquin, but according to his wife, he did continue to have low-grade temperatures. He does not experience any dysuria due to his prior surgery. He does not recall any abdominal pain or flank pain. He does also have a history of nephrolithiasis; he does still have a renal stone.
On approximately MM/DD/YYYY, the patient had a rapid worsening of his shortness of breath. He therefore went to the emergency department where he was found to be having an acute myocardial infarction. Since then, he was transferred to this facility with plans for cardiac catheterization and further workup per Dr. John Doe. The patient did have urine culture on MM/DD/YYYY, which was positive for greater than 100,000 colonies of E coli. This reportedly was obtained by catheterization from the urostomy. Urinalysis did have 20 to 50 white blood cells, 5 to 10 red blood cells, 4+ bacteria, and was positive for nitrite and positive for protein and blood.
The patient here was reportedly started on Cipro; although, the patient states, to his recollection, that he has had issues with bacterial resistance to Cipro in the past. We do not have the susceptibility that he had from outside facility, and we have requested these. So far, in the hospital, the patient has been afebrile.
MEDICATIONS: Carbidopa/levodopa, Lovenox, Mirapex, Protonix, Toprol-XL, Prozac, aspirin, Colace, and Cipro 250 mg p.o. b.i.d. Also, potassium replacement protocol.
PAST MEDICAL HISTORY: History of Parkinson’s, history of hypertension, and history of carcinoma of the bladder. Apparently, the bladder cancer diagnosis was made in (XXXX). The patient states that he was treated with BCG bladder instillation at that time. He actually had a good response initially; however, at about 5 years afterwards developed prostatitis, and biopsy was consistent with BCGosis/tuberculosis of the prostate for which he was treated with antimicrobial therapy for a prolonged period of time; he thinks at least 6 months and possibly longer. Then, later, the patient was found to have recurrence of bladder cancer in the prostatic urethra. He ultimately underwent radical cystectomy, including prostatectomy. He has had a continent urostomy created at that time. The patient also has history of prior right lower extremity DVT remotely and previously had been on anticoagulation, although that has since been finished. He has had history of diverticulitis for which he underwent bowel resection with primary anastomosis approximately 9 years ago. Also, history of hernia surgery, and he has had history of nephrolithiasis, including stone extraction from the bladder in which he had multiple infected stones in his urostomy pouch.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient is married. He is nonsmoker and nondrinker.
FAMILY HISTORY: Positive for cardiac disease in his sister and stroke in a brother and mother.
REVIEW OF SYSTEMS: The patient has also had a history of cholecystectomy. The patient denies any history of stroke or seizure disorder. No dysphagia, no odynophagia. No history of thyroid disease or goiter. No history of asthma or emphysema. As far as he is aware, he never had any history of pulmonary tuberculosis and only prostate disease. He denied any current abdominal pain. Denied diarrhea. Denies any generalized rash at this time. Please see HPI above and PMH above for the remainder.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8 degrees, pulse 72, blood pressure 122/74, respiratory rate 18, and O2 saturation 93% on 2 liters nasal cannula.
GENERAL: The patient is awake, alert, and in no acute distress.
HEENT: Pupils are reactive. Sclerae are anicteric. Conjunctivae are noninjected. Oral mucosa is moist. No thrush or pharyngitis.
NECK: Supple. Trachea midline. No palpable thyromegaly.
LYMPH NODES: No frank cervical or supraclavicular adenopathy.
LUNGS: Excursion is symmetrical. The patient has bilateral breath sounds without wheezes.
HEART: Regular rate and rhythm. No rub. No frank regurgitation or murmur.
ABDOMEN: Normoactive bowel sounds. No guarding. No rebound tenderness. No palpable hepatomegaly. The urostomy site appears to be pink and healthy with good granulation. No cellulitis evident.
BACK: No CVA tenderness.
EXTREMITIES: No clubbing or cyanosis. At this time, no palpable cords, although the patient has been found to have a DVT in the right lower extremity. No peripheral stigmata of endocarditis.
SKIN: Without diffuse rash. No vesicles or bullae. No Janeway lesions or Osler nodes.
LABORATORY DATA: White blood count 7.2, hemoglobin 12.4, and platelets 158,000. Creatinine 1.65 and BUN 27. Sodium 140, potassium 3.6. Urinalysis here had 12 white blood cells, 1+ bacteria, and negative for nitrite and negative for leukocyte esterase. Bilirubin 0.2, alkaline phosphatase 90, SGPT 15, and SGOT 34. The patient did have blood cultures drawn this morning at 0310 hours and 0445 hours and urine culture at 0310 hours, all of which are in progress.
DIAGNOSTIC DATA: V/Q scan was reportedly low probability. Chest x-ray raised the question of possible hiatal hernia.
IMPRESSION:
1. Positive urine culture for Escherichia coli from outside facility. Consider urinary tract infection from the patient’s urostomy pouch. The patient has had some low-grade fever and may need to consider the possibility of complicated urinary tract infection.
2. Reportedly chronic low-grade fever, of unclear etiology. Consider urinary tract focus. Rule out other process such as bacteremia. The patient also has now been found to have deep venous thrombosis, which might be contributory. Chest x-ray reportedly was negative for acute pulmonary infiltrate.
3. Status post recent acute myocardial infarction.
4. History of hypertension.
5. History of Parkinson’s.
6. History of carcinoma of the bladder. Initially diagnosed in (XXXX), then subsequently with recurrent disease in (XXXX) and at that time undergoing what sounds like a radical cystoprostatectomy and with creation of a continent urostomy.
7. History of bacille Calmette-Guerin treatment for bladder cancer and then with subsequent development of bacille Calmette-Guerin disease of the prostate and treated with antituberculosis therapy at that time.
8. Prior history of right lower extremity deep venous thrombosis.
9. This admission, the patient reportedly has had a deep venous thrombosis of right lower extremity.
10. History of stones in the patient’s urostomy pouch, and reportedly, these were infected and removed surgically in (XXXX).
11. History of nephrolithiasis.
12. History of hernia surgery.
13. History of cholecystectomy in (XXXX).
14. History of diverticulitis with bowel resection and primary reanastomosis.
15. Anemia.
RECOMMENDATIONS: We are awaiting further culture and sensitivity information. We are going to go ahead and give the patient IV Rocephin for additional gram-negative/E. coli coverage in anticipation of upcoming cardiac catheterization while awaiting culture results. Hopefully, antimicrobial therapy can be streamlined further once sensitive information is available. We have discussed situation with the patient and his wife, and their questions were answered.
