Infectious Diseases Consultation Medical Transcription Sample Reports

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Evaluation and management of painful lymphadenitis.

Thank you for this infectious diseases consultation.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female who about 4 days prior to admission noticed what appeared to be a painful inguinal lymph node on the left that seemed to progressively increase in size. This started while on a trip, but after she returned to work, she noticed it became a lot more tender and swollen. She finally presented to the emergency department after having a couple of days of onset of fever and was admitted for further evaluation. The patient on arrival did have a low-grade temperature of 100. She was started initially on Flagyl and Cipro, that was changed to doxycycline and Rocephin, and now she is on Zithromax and vancomycin.

The patient does shave her legs as well as her pubic area, but she did not have any known infection as far as she knows and she uses clean blades. The patient has not had any exposure to tuberculosis, although she said that she has had weight loss and some night sweats, but this has only started since the onset of her symptoms about a week ago. She has not had any long-term weight loss or long-term night sweats or cough. The patient had traveled for that weekend prior to getting her onset of symptoms but she did not do any camping. She does have two cats at home but no obvious cat bite or scratches as far as she knows. The patient has also been involved in a new sexual relationship about several months ago and has not had an HIV test recently. She had one two years ago that she reports was negative. No other history of sexually transmitted diseases to her knowledge.

REVIEW OF SYSTEMS: Done and is negative other than mentioned above. The patient had diarrhea one day prior to admission and currently still has diarrhea.

PAST MEDICAL HISTORY: Hypertension, history of kidney stones, depression, migraines.

PAST SURGICAL HISTORY: Cesarean section x2, cyst removed from the right leg.

ALLERGIES: No known allergies.

MEDICATIONS: List is currently reviewed and the antibiotics are listed above in the HPI.

SOCIAL HISTORY: The patient does not use tobacco, alcohol or drugs. She is divorced from her first husband but is living with a new boyfriend. She has four children and lives at home with them.

FAMILY HISTORY: Negative for immune dysfunction.

PHYSICAL EXAMINATION: General: The patient is alert and oriented and in no acute distress. She is afebrile. Temperature 96.5, pulse 70, respirations 19 and blood pressure is 115/73. HEENT: Pupils are equal and reactive. Head is normocephalic and atraumatic. Sinuses are nontender. Oropharynx is clear without lesions. Neck: Supple without lymphadenopathy. Heart: Regular rate and rhythm. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender and nondistended with no rebound or guarding. Good bowel sounds are heard. Genitourinary: The left groin reveals tender adenopathy. No obvious buboes are seen, but there is definite swelling and a mass felt in the left inguinal area. There is no obvious cut or scratches seen. The pubic hair is shaved. The rest of the inguinal area appears fairly unremarkable without lesions or blisters seen. Lower extremities are without edema, clubbing or cyanosis, and appeared normal. Skin: Reveals no rashes. Neurologic: Grossly nonfocal.

LABORATORY DATA: Laboratory data has been reviewed and showed an elevated white count of 16. There is a band neutrophilia of 27%. Liver function tests are unremarkable. Creatinine is normal. UA is unremarkable. Chlamydia and gonorrhea DNA probe are negative.

DIAGNOSTIC STUDIES: CT of the abdomen was done which was unremarkable. There is a nonspecific enlargement of a lymph node within the left inguinal region as seen on the CT of the pelvis.

IMPRESSION:

1. Painful lymph node lymphadenitis with a broad differential.
2. Diarrhea, which is new onset, right before admission.

DISCUSSION: The differential is broad. This could be suppurative bacterial process which is usually due to staph and strep. It is less likely to be tularemia or Yersinia. We also need to consider fungal, TB and sexually transmitted diseases including HIV. We also need to consider cat scratch disease.

RECOMMENDATIONS:

1. The most important thing is to get a CT-guided biopsy of that lesion.
2. We will order HIV antibody and quantitative viral load.
3. We will check Bartonella antibodies as well as Chlamydia trachomatis titers.
4. We will check PPD.
5. Check Clostridium difficile toxin.
6. Daptomycin antibiotic to replace the vancomycin.

We will continue to follow. Thank you for asking us to participate in this patient’s care.

Infectious Diseases Consultation Medical Transcription Sample Report #2

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Evaluation of MRSA in the sputum.

Thank you for this infectious diseases consultation.

HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old female with Alzheimer dementia. She apparently had fairly sudden onset of right hip and knee pain and was found to have a tibial fracture as well as severe degenerative arthritis of the right hip. This has been elected to be treated nonoperatively and conservatively. Her hospitalization has been complicated by the recognition of a mucoid Pseudomonas urinary tract infection that has been treated with Avelox. More recently, she has had increasing cough, congestion and yellow sputum production. Sputum cultures were obtained which grew out preliminary MRSA in the sputum. Chest x-rays did not show any obvious consolidation but an infectious disease consultation was requested to determine whether this signified an infection or whether perhaps this was more of a colonization. The patient is quiet demented and I am unable to get any history from her. She is unable to give me any review of systems either. However she is visibly coughing and obviously congested. The nurse tells me that the sputum has been yellow. She is on room air, however, but is saturating at 90-93%.

PAST MEDICAL HISTORY: Cardiomegaly with CHF, hypertension, osteoarthritis, osteopenia, Alzheimer dementia, arteriosclerotic cardiovascular disease, anxiety disorder and history of repeated urinary tract infections.

ALLERGIES: No known allergies.

CURRENT MEDICATIONS: List had been reviewed. It should be noted that she is on Avelox.

SOCIAL HISTORY: The patient lives in a nursing facility. She does not use tobacco or alcohol.

FAMILY HISTORY: Noncontributory.

PHYSICAL EXAMINATION: She is awake and alert. She tries to mumble things but they are incomprehensible. She does not follow commands. Vital Signs: She has been afebrile throughout most of her hospitalization. T-max was 100.6 on MM/DD/YYYY, currently 98.3, pulse 100, respirations 18, saturation 90% on room air and blood pressure 137/69. HEENT: The pupils are equal and reactive. Sinuses appear nontender. Nares are patent. Oropharynx is dry but no obvious lesions are seen. The neck is supple without lymphadenopathy. Heart has regular rate and rhythm. Lungs reveal a few rhonchi but otherwise clear without any wheezes. Abdomen is benign without tenderness, distention. There are good bowel sounds heard. The extremities appear fairly normal without edema, cyanosis or clubbing. Skin is warm and dry without rash.

LABORATORY DATA: Laboratory data have been reviewed. Her white count is slightly elevated at 14.6. It was as high as 17. There was no left shift seen. Creatinine is normal. Urine cultures grew out mucoid pseudomonas species sensitive to Cipro. Sputum grew out preliminary MRSA. Blood cultures have been sterile so far.

DIAGNOSTIC STUDIES: Chest x-ray shows some atelectasis in the left perihilar region. No definite consolidation and some mild interstitial markings.

IMPRESSION:
1. Methicillin-resistant Staphylococcus aureus tracheobronchitis.
2. Pseudomonas urinary tract infection.
3. Right hip pain with degenerative joint arthritis of hip.
4. Tibia fracture.
5. Alzheimer senile dementia.

DISCUSSION: I believe that the MRSA represents a true infection given the symptoms that she has had and the signs she exhibited. Fortunately, there does not appear to be a lobar pneumonia, so this appears to be largely localized to the tracheobronchial tree. However, it should be treated given the fact that she is slightly hypoxic, has cough and has the MRSA in the sputum.

RECOMMENDATIONS:
1. I would switch her Avelox to Cipro because Cipro gets better urinary penetration and I would treat her to complete 7 days.
2. We will begin Zyvox for tracheobronchitis to complete 7 days. The route of administration could be orally if she can take oral medications, otherwise we can give it IV.

Thank you for asking us to participate in this patient’s care. We will continue to follow with you.

Infectious Diseases Consultation Medical Transcription Sample Report #3

DATE OF CONSULTATION: MM/DD/YYYY

REFERRING PHYSICIAN: John Doe, MD

REASON FOR CONSULTATION: Evaluation and management of groin abscess.

Thank you for this infectious diseases consultation.

HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old white male with a history of previous abscesses in multiple locations, who started noticing about 4-5 days ago a pimple over the inner thigh in the groin area which worsened and became much more painful over the next few days. He tried to pop it as he did most of his other abscesses and there was some blood and purulence expelled, but the area continued to grow and he became concerned and came to the emergency department for further evaluation. He did not have any systemic symptoms. He did feel a few chills, possibly fevers, but nothing really significant. He was evaluated in the ED and taken to the OR with the diagnosis of Fournier gangrene and had an incision and drainage done. The patient is currently feeling much better intraoperatively. The patient has had recurrent abscesses that have been fairly well controlled without antibiotic management. These have occurred under the arm and in the groin before as well as the buttocks, and have occurred over the last few years. Normally, he pops it and it does not cause any problems. He has not sought medical attention for that. He did have an I&D of the right wrist secondary to an injury in which the wound grew out MRSA.

PAST MEDICAL HISTORY: Otherwise negative. He did have a right wrist infection secondary to trauma and was hospitalized. At that time, he did have MRSA growing from that wound. He has also had hernia repair x2.

MEDICATION: Lists are reviewed. He is on vancomycin, Zosyn and clindamycin.

SOCIAL HISTORY: He does use tobacco. No alcohol or drugs. He has had previous relationships with women who have had risk factors for HIV and has been tested a couple of years ago and that was negative.

REVIEW OF SYSTEMS: Otherwise negative

PHYSICAL EXAMINATION: He is an alert and oriented gentleman in no acute distress. Temperature 99.5, pulse 90, respirations 22 and blood pressure is 101/71. HEENT: Benign. Oropharynx is clear. Neck is supple without lymphadenopathy. Heart is regular rate and rhythm. Lungs are clear to auscultation bilaterally. Abdomen is soft, nontender and nondistended. The left groin and inner thigh is completely bandaged up. This is just one day postoperative and I did not remove those bandages, but the area that is adjacent to the bandaged area appears soft without tenderness or cellulitis. He does have some difficulty with movement of his hips, especially on his left, secondary to pain. The lower extremities are without edema, cyanosis or clubbing. Skin is otherwise normal.

LABORATORY DATA: Wound culture is growing out preliminary MRSA. White count was elevated at 14.5. All other laboratory data were reviewed.

IMPRESSION/PLAN: Methicillin-resistant Staphylococcus aureus abscess of the left inner thigh/groin, status post incision and drainage. This is unlikely Fournier gangrene. Treatment at this time would consist of antibiotic management, continued local wound care. We should consider prevention measures including methicillin-resistant Staphylococcus aureus screen of the nares. I will also check an human immunodeficiency virus test on him again and will start daptomycin IV on him.

Thanks for allowing me to participate in this patient’s care. I will continue to follow.