Consult - History and Phy.
Sample Name: Gen Med Consult - 47
Description: The patient had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.
(Medical Transcription Sample Report)
HISTORY OF PRESENT ILLNESS: This is a 76-year-old female that was admitted with fever, chills, and left pelvic pain. The patient was well visiting in ABC, with her daughter that evening. She had pain in her left posterior pelvic and low back region. They came back to XYZ the following day. By the time they got here, she was in severe pain and had fever. They came straight to the emergency room. She was admitted. She had temperature of 104 degrees F. It has been spiking ever since and she has had left sacroiliac type hip pain. Multiple blood studies have been done including cultures, febrile agglutinins, etc. She has had run a higher blood glucose to the normal and she has been on sliding scale insulin. She was not known previously to be a diabetic. All x-rays have not been helpful as far as to determine the etiology of her discomfort. MRIs of the lumbar spine and the pelvis and both thighs have been unremarkable for any inflammatory process. She does have degenerative disk disease of her lumbar spine but no hip pathology. She has swollen inguinal nodes bilaterally.
PAST MEDICAL HISTORY AND REVIEW OF SYSTEMS: She was not known to be a diabetic until this admission. She had been hypertensive. She has been on medications and has been controlled. She has not had hyperlipidemia. She has had no thyroid problems. There has been no asthma, bronchitis, TB, emphysema or pneumonia. No tuberculosis. She has had no breast tumors. She has had no chest pain or cardiac problems. She has had gallbladder surgery. She has not had any gastritis or ulcers. She has had no kidney disease. She has had a hysterectomy. She has had 9 pregnancies and 8 living children. She had A&P repair. She had a sacral abscess after a spinal. It sounds to me like she had a pilonidal cyst, which took about 3 operations to heal. There have been fractures and no significant arthritis. She has been quite active at her ranch in Mexico. She raises goats and cattle. She drives a tractor and in short, has been very active.
PHYSICAL EXAMINATION: She is a short female, alert. She is shivering. She has ice in her axilla and behind her neck. She is febrile to 101 degrees F. She is alert. Her complaint is that of hip pain in the posterior sacroiliac joint area. She moves both her upper extremities well. She can move her right leg well. She actually can move her left hip and knee without much discomfort but the pain radiates from her sacroiliac joint. She cannot stand, sit or turn without severe pain. She has normal knee reflexes. No ankle reflexes. She has bounding tibial pulses. No sensory deficit. She says she knows when she has to void. She has a healed scar in the upper sacral region. There is some bruising around the buttocks but the daughter says that is from her being in bed lying on her back.
PLAN: My plan is to do a triple-phase bone scan. I am suspecting an infection possibly in the left sacroiliac joint. It is probably some type of bacterium, the etiology of which is undetermined. She has had a normal white count despite her fever. There has been a history of brucellosis in the past, but her titers at this time are negative. Continue medication which included antibiotics and also the Motrin and Darvocet.
Keywords: consult - history and phy., inflammatory, degenerative, fever, lumbar spine, sacroiliac joint, inguinal, sacroiliac, hip,