Sample Report: Pneumocystis Carinii Pneumonia
REASON FOR CONSULTATION: Rule out Pneumocystis pneumonia.
HISTORY OF PRESENT ILLNESS: This elderly Caucasian male has been on vacation, visiting his family. He is being evaluated to rule out Pneumocystis carinii pneumonia (PCP).
The patient recalls that he was in good health until around the time he was preparing to leave on vacation. At that time, he began to experience a dry, nonproductive cough, shortness of breath, dyspnea on exertion, and a low-grade fever. He has also had anorexia accompanied by an approximate 10-pound, unexplained weight loss. Because he has continued to experience symptoms, his family convinced him to seek care.
He was evaluated by his family physician, who felt that he had an atypical infection. He was given a 5-day course of Zithromax. Unfortunately, the patient failed to improve. A chest x-ray revealed bilateral interstitial and alveolar consolidation, consistent with PCP. For that reason, he was admitted to the hospital for further examination. He was started on Levaquin and Rocephin and was seen by the consulting pulmonologist.
The pulmonary consultant expressed concerns about the possibility of HIV, and appropriate serology was obtained. Today the patient was informed that his HIV status is positive, and he was placed on Septra and steroids. He is also continuing Levaquin and Rocephin.
Today the patient's primary complaints relate to his extreme shortness of breath and a dry, nonproductive cough. He does not complain about head or neck problems, nor does he have GI or GU complaints.
PAST MEDICAL AND SURGICAL HISTORY: Significant for hepatitis B and C, colon polyps, and a positive PPD test for tuberculosis. It is of interest that he cannot remember receiving treatment for the hepatitis or positive PPD. Denies history of illicit drug use. He has no history of hypertension, diabetes, or psychiatric disorder. Surgeries include tonsillectomy, appendectomy, tympanoplasty, colon polypectomy, and tendon repair on the right lower extremity following a skiing accident.
MEDICATIONS: The patient is taking Levaquin, Rocephin, and Septra.
ALLERGIES: He has no known allergies.
SOCIAL HISTORY: The patient has had a homosexual lifestyle that began in his mid teens. He has had several partners but has been sexually inactive for approximately 2 years. He does not know the status of any of his partners. He has smoked 1 pack of cigarettes per day for 45 years. He enjoys an occasional glass of wine. He is retired from his career as a retail store manager.
REVIEW OF SYSTEMS: As stated above.
PHYSICAL EXAMINATION: GENERAL: This is a rather cachectic patient, who appears to be acutely ill. He experiences mild respiratory distress as soon as he starts talking. VITAL SIGNS: Vital signs are recorded on his chart and reveal that his temperature has been as high as 103, but he is currently afebrile. HEENT: Unrevealing. Oral cavity is without thrush. BACK: Benign. PULMONARY: Chest reveals bilateral dry rales throughout. No pleural rub heard. CARDIOVASCULAR: Heart is tachycardic. S1, S2 without significant rub. There is a flow murmur of about 2/6. ABDOMEN: Bowel sounds are present. Abdomen is soft and nontender. Liver and spleen are not palpable. GENITALIA: Male genitalia normal, without a catheter. RECTAL: Rectal exam deferred. EXTREMITIES: Extremities are without unusual rash, lesion, or joint effusion.
NEUROLOGIC: He is awake, alert, and oriented.
LABORATORY DATA: Potassium 3.4, sodium 136, glucose 191, BUN 10, creatine 0.7, albumin 2.5, total bilirubin 1.2. SGOT 90, SGPT 51, LDH 300, and alkaline phosphatase 6.5. White blood count 7100 and platelets 66,000. Differential reveals 87 polys, 7 bands, 5 lymphs. Arterial blood gas: pH 7.6, PCO2 32, PO2 46 on room air.Chest x-ray shows diffuse changes consistent with Pneumocystis carinii pneumonia. HIV is positive. Western blot is pending.
ASSESSMENT AND PLAN: Findings on chest x-ray, the 3-week history of fever, shortness of breath, dry cough, dyspnea on exertion, elevated LDH, and HIV positive status support the diagnosis of Pneumocystis. Current treatment plan is acceptable, though the steroid dosage should be reduced because it appears that this is not a community-acquired pneumonia. Levaquin and Rocephin have been discontinued.
The patient has been counseled, including the fact that mortality can reach 15% to 20% despite best efforts, and all his questions were answered.