DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Postoperative fever.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who had elective right total knee replacement. Postoperatively, she has had fever, temperature maximum of 102.6 degrees yesterday. She denies any cough, chest pain, shortness of breath, abdominal pain, nausea, vomiting, diarrhea or dysuria.
PAST MEDICAL HISTORY: Diabetes, hyperlipidemia, hypertension, anemia, osteoarthritis, and thyroid dysfunction.
PAST SURGICAL HISTORY: Partial thyroidectomy; left breast lumpectomy, which was benign; C-section; and tubal ligation.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient is on Protonix, Vytorin, Amaryl, Niferex, Maxzide, Altace, Toprol-XL, and Epogen.
SOCIAL HISTORY: The patient denies smoking, alcohol or drug use.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As per HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature of 100.8 degrees, temperature maximum 102.6 degrees, pulse 92, respirations 18, and blood pressure 126/66.
HEENT: Unremarkable. No lymphadenopathy.
LUNGS: Clear to auscultation.
HEART: S1, S2, regular rhythm. The patient may have a grade 1/6 murmur at the apex.
ABDOMEN: Benign.
EXTREMITIES: Right knee surgical site had mild serosanguineous discharge on the dressing with mild tenderness.
NEUROLOGIC: No focal neurological deficits.
LABORATORY DATA: White count 8.6, hemoglobin 8.4, and platelets of 168,000. BUN and creatinine of 25 and 2. Urinalysis within normal limits.
DIAGNOSTIC DATA: CT scan of the chest shows no infiltrates, has goiter.
IMPRESSION: Postoperative fever, status post right total knee replacement. Could be secondary to hematoma at the surgical site. The patient did have bleeding from the incision line yesterday. There is no other obvious focus.
RECOMMENDATIONS:
1. Blood cultures x2.
2. Impregnate doxycycline for her probable indolent infection at the surgical site.
3. We would observe for at least the next 24 hours for any fevers.
Thank you for referring this patient.
