Inpatient Consultation
Patient Case Number: IPC67- Greenberg, Crystal
Patient Name: Crystal Greenberg | DOB: 03-04-62 | Sex: F
Date of Service: 08-22-XX | Physician: Charmaine Burrows, MD

# Reason for Consultation: Bacteremia possibly d/t Mediport

# History of Present Illness:

This is a 56 y/o female who presents the ABC Hospital’s Emergency Department from her oncologist secondary to fevers. Patient has a history of stage IV pancreatic cancer with colon cancer. She is also noted to have metastases to the liver. She is currently on chemotherapy treatment. She was febrile, 102°F, at home and spoke with her oncologist Dr. Renner, who stated that she needed to present to the emergency department. Blood cultures were performed showing staph aureus bacteremia. Patient had a Mediport placed 3 months ago by Dr. Gleason at XYZ Hospital. She is having pain and erythema around the port site and we are being counseled as to possible removal of this Mediport. Patient has been febrile since admission.

# Medical History: Muir-Torre Syndrome, htn, Chronic Afib

# Surgical History: Hysterectomy, Oophorectomy, breast reduction, appendectomy

# Social History: Former Smoker

# Medications: Furosemide 20mg, Metoprolol 100mg, Xarelto 20mg

# Allergies: Fresh pineapple Review of Systems Constitutional: Fevers.

# HEENT: No headache, visual changes or hearing changes.

# Respiratory: No shortness of breath or cough.

# Cardiovascular: No chest pain, palpitations, or syncopal like episodes.

# Gastrointestinal: Pancreatic/Colon/Liver cancer.

# Genitourinary: No burning, urgency, or frequency.

# Skin: No rashes, abrasions, or lacerations.

# Neurological: No neurologic deficits.

# Vitals:

Temperature | 97.8°F
Pulse | 67
Respirations | 18
Blood Pressure | 1120/70
SpO2 | 92% on room air

# Physical Examination:

# Constitutional: Chronically ill-appearing, Appears comfortable, no acute distress. HEENT: No nasal drainage, external ears appear normal, mucous membranes moist. Eyes: PERRLA

# Neck: Trachea midline

# Cardiovascular: Regular rate and rhythm, no murmurs, rubs or gallops Pulmonary/Chest: Left anterior chest shows a Mediport with excess mucosa place. There is erythema and some purulent drainage. There is some tenderness palpation over the Mediport. No use of accessory muscle, chest was clear to auscultation bilaterally, no wheezing, no crackles.

# Gastrointestinal: Abdomen was soft, non-tender, non-distended, no masses felt, no hepatosplenomegaly.

# Musculoskeletal: No clubbing or cyanosis, full range of motion in all extremities.

# Neurological: No focal motor or sensory deficits.

# Psychiatric: Alert and oriented x 3. Appropriate mood and affect.

# Laboratory Data:

# Test Result

HGB | 9.0*
PLT | 62*
NA | 136
K | 2.6*
CL | 94*
CO2 | 29
BUN | 10
CREAT | 0.8
CALCIUM | 7.9*
ALB | 2.5*
BILI TOTAL | 0.7
BILIDIRECT | 0.2
ALP | 62
ALT | 31
AST | 46*
INR | 4.48*
AMYLASE | 23*
LIPASE | 10*

# Assessment and Plan

1. Staph Aureus bacteremia w/ Mediport as source

2. Stage IV primary pancreatic cancer with primary colon cancer and mets to the liver

3. Hypertension

4. Chronic atrial fibrillation

5. Muir Torre Syndrome

# Electronically Signed By: Charmaine Burrows, MD

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