DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Asthma exacerbation.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Asian female with long-standing history of severe bronchial asthma. The patient reports that over the past week or so, she has developed increased shortness of breath with wheezing and a productive cough. She has been bringing up white phlegm. She reports no documented fevers or chest pain. She has also noted that her blood pressure and heart rate have been increased. The patient called to our office about a week ago and was taking a prednisone taper starting at 60 mg. Once she cut down to 30 mg, her shortness of breath increased greatly, which was today. The patient did present at our office today with heart rate elevated at 120 and regular rhythm and saturation 95% on 3 liters.
ABG was as follows: Her pH was 7.34, PCO2 was 42, PO2 was 118, bicarbonate 24, base excess was -1.5. Overall chest x-ray was unrevealing with no evidence of pneumonia.
ALLERGIES: SULFA.
PAST MEDICAL HISTORY: Significant for severe bronchial asthma, history of bilateral upper extremity DVTs, morbid obesity, insulin-dependent diabetes mellitus, hypertension, depression and anxiety, breast biopsies, incision and drainage of a right breast abscess, foot surgery, and possible questionable obstructive sleep apnea.
SOCIAL HISTORY: The patient lives at home with her husband. They have four children. She does not currently smoke, drink or use any illicit drugs.
REVIEW OF SYSTEMS: The patient does present with shortness of breath and a productive cough with white phlegm. She has no hemoptysis. She has no chest pain. She does have chronic lower back pain and pain in the extremities, which is also common. No nausea, vomiting, diarrhea, constipation or abdominal pain. No numbness or weakness. She does have a history of positive depression, currently taking Paxil for this, as well as anxiety for which she takes Xanax. No fevers or reported chills.
PHYSICAL EXAMINATION: On physical exam today, blood pressure is 138/88, pulse 120, respirations 26, temperature 98.4, and 95% on 3 liters. She is alert and oriented x3, in no apparent distress. The patient is mildly tachypneic. HEENT: Pupils are round and reactive. Nasal passages are patent. There is no exudate noted in the throat. Neck is supple. Trachea midline. Heart: S1 and S2, elevated rate, normal rhythm. Lungs: Do reveal scattered expiratory wheezes, diminished in the bases. Abdomen: Obese, soft, and nontender. Positive bowel sounds. Extremities: Reveals trace bilateral lower extremity edema. No cyanosis or clubbing. Neurologic: Nonfocal. Cranial nerves are intact. Skin: Warm without rash. Lymphatics: No lymph nodes palpated in the neck, supraclavicular or axillary area.
DIAGNOSTIC STUDIES: Chest x-ray reveals overall no cardiopulmonary disease. There is mild cardiomegaly, and there is some mild left lower lobe atelectasis. There are no significant pleural effusions appreciated. No pneumothorax.
IMPRESSION:
1. Severe chronic persistent asthma with asthmatic bronchitis exacerbation.
2. Bilateral upper extremity deep venous thrombosis. The patient is currently taking Coumadin for this. Most recent Doppler was negative.
3. Insulin-dependent diabetes mellitus. The patient is on insulin pump.
4. Obesity.
5. Chronic pain syndrome.
6. Hypertension.
7. Depression and anxiety disorder.
8. Tachycardia.
9. History of abnormal CAT scan with scattered lung nodules.
RECOMMENDATIONS:
1. The patient is to be admitted to either PCU or medical floor with telemetry.
2. The patient was given Kenalog 60 mg IM in our office today as well as ABG was completed, which was outlined above. The patient will resume 1800 ADA calorie diet. The patient will be performing own Accu-Cheks and adjusting her insulin pump.
3. The patient will have EKG.
4. The patient will have CBC with differential, CMP, PT, PTT, INR, UA with C&S and theophylline level drawn.
5. We will administer Solu-Medrol 80 mg IV q.6 h.
6. The patient will continue current home medications.
7. The patient will use Xopenex 1.25 mg via nebulizer q.6 h. secondary to tachycardia.
8. Tessalon Perles 200 mg p.o. t.i.d. p.r.n.
9. Cefepime 2 grams IV q.12 h.
10. Zithromax 500 mg IV daily.
11. The patient will continue CPAP at current settings of 10 cm of water at bedtime.
12. The patient will have PICC line insertion.
13. We will monitor care for this patient.
