MRSA Pneumonia Consult Transcription Sample Report
DATE OF OPERATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: MRSA pneumonia, possible UTI, fever.
HISTORY OF PRESENT ILLNESS: This is an (XX)-year-old female with a history of recent stroke, who was transferred from nursing home with complaint of increased cough. The patient also complained of some pulmonary congestion with low-grade fever and was started on Zosyn by the primary care physician. ID was consulted secondary to MRSA being found in the sputum cultures. Most of the information was obtained through the patient’s son, as the patient is currently nonverbal secondary to her stroke. At this time, the patient’s son states she has been aspirating while at the nursing home with increasing cough and decrease in overall status secondary to prior events. Currently, the patient appears to be resting comfortably without any complaints. She is somewhat drowsy after receiving several hours of therapy earlier this morning.
PAST MEDICAL HISTORY: CVA, hypertension, and atrial fibrillation. The patient is currently a DNR per family request.
PAST SURGICAL HISTORY: PEG placement and pacemaker placement.
FAMILY HISTORY: Hypertension.
SOCIAL HISTORY: The patient is currently a nursing home resident. Denies tobacco, alcohol or drugs.
CURRENT MEDICATIONS: Zoloft, multivitamin, guaifenesin, diltiazem, vancomycin, Synthroid, potassium, Prevacid, Solu-Medrol, digoxin, and Bumex.
ALLERGIES: NKDA.
REVIEW OF SYSTEMS: Except for the above, no other cutaneous, neurologic, lymphatic, endocrine, cardiovascular, respiratory, gastrointestinal, genitourinary, musculoskeletal, or systemic complaints or events have been noted recently.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 101.4 degrees maximum, now 98.6 degrees, blood pressure 104/38, pulse 72, and respiratory rate 22.
SKIN: There is no skin rash, generalized lymphadenopathy, cyanosis or jaundice.
HEENT: There is no conjunctivitis or rhinorrhea. There is no sinus tenderness, oral thrush, or other intraoral lesions. There is no facial rash or otorrhea.
NECK: The patient has no nuchal rigidity, JVD or neck lymphadenopathy. There is no palpable neck mass.
HEART: There is no gallop, rub or murmur.
LUNGS: The patient is noted to have rales throughout.
ABDOMEN: PEG tube is clean, dry, and intact.
GENITOURINARY: Foley in place.
EXTREMITIES: There are no cellulitis changes of the lower extremities. There is no joint tenderness or palpable subcutaneous nodules. There is no clubbing or edema.
NEUROLOGIC: The patient is somewhat drowsy, has some right-sided weakness, and is nonverbal.
LABORATORY DATA: Laboratory performed today reveals white count 7.4, hemoglobin 11.6, hematocrit 34.2, platelets 254,000, creatinine 1.2, bands 25%. LFTs are negative. BNP 494. Urinalysis revealed greater than 180 wbc’s, occasional wbc clumps, 3+ leukocyte esterase but no bacteria. Blood cultures were negative, 2/2 bottles. Sputum cultures revealed MRSA and E. coli.
Abdominal x-ray was negative. Chest x-ray revealed probable CHF, possible new pneumonia, as the patient has patchy infiltrates. Followup chest x-ray revealed cardiomegaly with left basilar consolidation and atelectasis, development of right upper lobe infiltrate.
ASSESSMENT AND PLAN:
1. This is a patient assessed for positive sputum cultures with methicillin-resistant Staphylococcus aureus and Escherichia coli with new chest x-ray changes suspicious for pneumonia, possible aspiration. There is no current evidence of respiratory failure at this time. In the meantime, we will continue vancomycin for methicillin-resistant Staphylococcus aureus and we will add Rocephin for Escherichia coli per sensitivity data. If there is no improvement in the patient’s status, we will consider changing vancomycin to Zosyn, and we will plan approximately a 10- to 14-day antibiotic course.
2. Gram-negative urinary tract infection with significant urinalysis changes. Organism is unknown at this time. Okay to continue Rocephin while awaiting final culture results. We will plan approximately a 5- to 7-day antibiotic course, and we will have Foley catheter change.
3. Fever, most likely secondary to pneumonia and urinary tract infection.
Thank you for this consultation. We will follow the patient along with you.
