DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: UTI and vaginitis.
HISTORY OF PRESENT ILLNESS: This is a XX-year-old female patient who was admitted to the CCU. The patient has known congestive heart failure, cardiomyopathy and atrial fibrillation. She was found to have UTI and ID consult was done. The patient has a Foley catheter in place. No fever, no chills, no rigor, no hematuria, no abdominal pain but she is short of breath.
PAST MEDICAL HISTORY: Congestive cardiomyopathy, congestive heart failure, atrial fibrillation and history of minor stroke.
PAST SURGICAL HISTORY: Abdominal surgery and PTCA. She has a Swan-Ganz catheter.
ALLERGIES: No drug allergies.
SOCIAL HISTORY: She denied smoking, alcohol abuse, using drugs.
FAMILY HISTORY: Noncontributory.
MEDICATIONS: She was on Maxipime, vancomycin and started on Diflucan. The patient is also on Altace, Coreg, digoxin and Ambien. She is on dopamine, Dobutrex, and vasopressin.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No loss of weight. No fever.
HEENT: No headache, earache, ear discharge or sore throat.
CHEST: No cough. No expectoration.
CARDIAC: She has shortness of breath and heart failure.
GASTROINTESTINAL: No nausea. No vomiting. No diarrhea.
SKIN: No rash.
JOINTS: No swelling.
HEMATOLOGICAL: No easy bruising or bleeding from the orifices.
PHYSICAL EXAMINATION:
GENERAL: The patient is fully conscious and oriented.
VITAL SIGNS: Temperature is 98.1 degrees, blood pressure is 98/70 and respiratory rate is 18.
HEENT: She has clear conjunctivae, anicteric sclerae.
NECK: Supple. Thyroid is normal. Trachea is central. JVD is negative. Carotid ultrasound is normal. She has Swan-Ganz catheter in the right subclavian area.
CHEST: Showed crackles at the base.
HEART: Normal.
ABDOMEN: Soft in all four quadrants. No tenderness or organomegaly.
EXTREMITIES: No edema, clubbing or cyanosis.
NEUROLOGIC: The patient is fully conscious.
LABORATORY DATA: White blood cells 18,700, hemoglobin 7.2, hematocrit 22.8 and platelet count 304,000. Neutrophils 82 and lymphocytes 10. INR 1.3 and PTT 37. Sodium 136, potassium 3.7, chloride 103, CO2 of 26, glucose 103, BUN 7, creatinine 0.8, calcium 7.5, phosphate 3.2, magnesium 1.7, and glucose 92. Digoxin is 1. The iron is less than 10, TIBC is 206 and ferritin is 25. Urinalysis shows white blood cells more than 30, nitrite is positive. She has yeast, blood and also gram-negative rods. Arterial blood gases; pH 7.37, CO2 of 48.9, bicarbonate 28.1, and oxygen 45.4. T3, T4 and TSH are within normal limits. Occult blood is positive.
Chest x-ray, no active infiltration, but she has cardiomegaly. Ultrasound of the abdomen, uterus and ovary are not visualized and they presumably have been removed.
IMPRESSION: In summary, this is a XX-year-old female patient admitted with the following:
1. Urinary tract infection secondary to gram-negative rods and yeast.
2. Vaginitis.
3. Hypotension, on inotropic support, which is likely to be secondary to cardiomyopathy, infection also could be contributing.
4. History of cardiomyopathy, congestive heart failure, atrial fibrillation, percutaneous transluminal coronary angioplasty as well as cerebrovascular accident.
PLAN: We will discontinue vancomycin and keep the patient on Maxipime and Diflucan. Change Foley catheter. Further management will depend upon the result of culture and sensitivity.
Thank you for the consultation.
