DATE OF CONSULTATION: March 3, 2013 HISTORY OF PRESENT ILLNESS: The patient is a very unfortunate gentleman, 40 year s old, who

has transverse myelitis with high C-spine quadriplegia, history of sa cral decubiti, extremity decubiti, history of knee surgery, rotator cuff surgery and tracheostomy. We sent multiple septic episodes for urinary tract infection, had a sigmoid colectomy and colostomy secondary to colonic inertia and has colo stomy in place that is not problematic. The patient was admitted to the hospital now, dehydrated, feeling poorly with intractable nausea, vomiting and hematemes is. His white count was somewhat elevated. His urinalysis is abnormal with Gramnegative rods in his urine and he is here with us trying to figure out what is g oing on. He has a CT of his abdomen, which shows what looks like either probably atelectasis of left lower lobe. The imaging study of his lungs is incomplete. W e will get a full CT of his chest. I do not really see real infiltrate or fluid collection in the chest x-ray, but it is hard to determine, so we will have to d o a dedicated study. PAST SURGICAL HISTORY: As above. ALLERGIES: None. MEDICATIONS: 1. Alprazolam. 2. Baclofen. 3. Colace. 4. Fenofibrate. 5. Fludrocortisone. 6. Glucosamine. 7. Hydrogen sulfide. 8. Lactobacillus. 9. Midodrine. 10. Niacin. 11. Protonix. 12. Potassium chloride. 13. Restoril. 14. Zolpidem. 15. Multivitamins. 16. Oxycodone. SOCIAL HISTORY: The patient does not smoke or drink. He is at home. REVIEW OF SYSTEMS: His review of systems is otherwise negative except as noted i n the history of present illness. The patient has been given 5 liters of fluid i n the ER, his pressure is up some. He was hypotensive. His blood cultures so far are negative and his urine cultures growing Gram-negative rods. I am not clear exactly how this is all going to put together. PHYSICAL EXAMINATION: GENERAL: A pleasant gentleman, in no acute distress, lying comfortably in bed. VITAL SIGNS: His temperature is 98.4, 100.2 10 hours ago, heart rate is about 11 0, respiratory rate is 14. Blood pressure 97/65. SKIN: Shows decubiti, multiple. HEAD, EARS, EYES, NOSE, AND THROAT: Negative. NECK: Carotids show no bruits. Thyroid is normal. LUNGS: Relatively clear to percussion and auscultation though I cannot hear very well in the back. ABDOMEN: Shows liver and spleen of normal size. Tracheostomy is intact. Colostom y is fine. No parastomal abscess. EXTREMITY EXAMINATION: No clubbing, cyanosis, or edema. Toes are flexed with con tracture. The patient is spastic.

LYMPH NODE: Negative. SKIN: Otherwise as noted earlier. IMPRESSION AND PLAN: This gentleman has multiple sources of infection, the urine , lung and skin. Antimicrobials ordered. We will make some adjustments; however, a CT of the chest should be done and this gentleman does have atelectasis of hi s left lower lobe, which _____???(03:30). We will do something about it. He is r eceiving both metronidazole and Piperacillin and vancomycin. The patient _____?? ?(03:37). There is no real reason to give metronidazole. At this point, we will stop that. Vancomycin can be given per levels and _____ dose is fine, but we wil l have to go see what is going on here. Creatinine is reasonable, so for the mom ent, we will have some difficult decisions. Meropenem is probably a better choic e in this gentleman than Piperacillin/tazobactam only because of recurring infec tions this gentleman has had. _____has had do Klebs or E. coli, but this is pure ly form safe for the moment. Let me add meropenem or substitute it, and probably we will substitute it; otherwise, we will monitor his vancomycin levels and see his chest CT and see _____???(04:25) next 24 hours.

CC: / 6010190 / D: 03/04/2013 09:20:31,est /TD: 03/04/2013 10:16:14, est / Job#: 89 15173 / Voice ID: 8183742 / Rev: 03/04/2013 10:16:14