DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Aspiration pneumonia.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old female who was admitted with fever and weakness. The patient was also coughing. She was found to have right-sided infiltrate on chest x-ray. She was started on Avelox for possible aspiration pneumonia. She failed the swallowing evaluation and hence had a NG tube placement today for feeding reasons. Fevers have defervesced and are still low grade at 100.6. History is mainly obtained from the chart. The patient had a CT of the chest on admission, which revealed a questionable aortic dissection, granulomatous scarring, and right middle lobe infiltrates.
PAST MEDICAL HISTORY: History of frequent falls, otherwise unobtainable.
PAST SURGICAL HISTORY: Unobtainable.
MEDICATIONS: The patient is on Avelox.
ALLERGIES: ALLERGIC TO PENICILLIN AND SULFA, QUESTIONABLE MYCINS.
SOCIAL HISTORY: The patient lives alone. She denies smoking, alcohol or drug use.
FAMILY HISTORY: Unobtainable.
REVIEW OF SYSTEMS: As per history of present illness, otherwise unobtainable.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 100.6, pulse 102, respirations 18, and blood pressure 168/74.
HEENT: Unremarkable.
NECK: No lymphadenopathy.
LUNGS: The patient has decreased breath sounds bilaterally with a few crackles at the bases.
HEART: S1 and S2. Regular rhythm.
ABDOMEN: Soft. Bowel sounds present. No tenderness.
EXTREMITIES: No edema, clubbing or cyanosis.
NEUROLOGIC: The patient is alert and awake and may be a little bit confused.
LABORATORY DATA: White count 10,400, hemoglobin 12.2, and platelets 206,000. BUN and creatinine 11.6 and 0.8. Liver function tests within normal limits. Blood culture and urine culture negative so far.
IMPRESSION: Aspiration pneumonia, clinically doing okay, but still has some low-grade fevers.
RECOMMENDATIONS:
1. Continue Avelox. Add Flagyl for additional anaerobic coverage.
2. Consider PEG tube.
3. Repeat chest x-ray.
4. Will also get lower extremity duplex.
Thank you for this consultation. Appreciate the opportunity to participate in the care of this patient. If you have any questions, please do not hesitate to contact us.
