DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Hypotension and critical care management.
HISTORY OF PRESENT ILLNESS: The patient is an unfortunate (XX)-year-old female with history of hypertension, hypothyroidism, and hepatitis C who was diagnosed three months ago with head and neck carcinoma. She was seen by Dr. John Doe and underwent staging workup. Workup included a PET scan, which showed metastases to the lungs also to the tongue and neck nodes. The patient underwent PEG placement for feeding access, and she was started on Taxotere, cisplatin, and 5-FU. According to the patient, she had her last chemotherapy on Tuesday and apparently she was admitted yesterday because of dehydration. The patient has been transferred to the ICU overnight because of hypotension. She has received IV fluids. She is now on Neo-Synephrine drip. The patient was interviewed. She is awake, alert, and does admit to history of tobacco abuse, probably 30-pack years, quit three months ago. She does use albuterol inhaler at home. She admits cough with mostly clear sputum. She denies chest pain. She denies significant shortness of breath.
PAST MEDICAL HISTORY: As mentioned.
PAST SURGICAL HISTORY: Hernia repair, appendectomy, and PEG placement.
MEDICATIONS AT HOME: Aldactone, nadolol, Synthroid, Xanax, magnesium, albuterol, and Prevacid.
ALLERGIES: None.
SOCIAL HISTORY: Tobacco as mentioned. ETOH: The patient quit 15 years ago.
REVIEW OF SYSTEMS: A 14-point review is significant for what is mentioned above.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 90/50, pulse 84, respirations 20.
GENERAL: Chronically ill appearing female who is awake, alert, in no distress.
HEENT: Alopecia.
NECK: Supple.
LUNGS: Revealed bilateral breath sounds with few scattered rhonchi.
HEART: S1 and S2, regular.
ABDOMEN: Soft bowel sounds are present.
EXTREMITIES: No clubbing, no cyanosis, and no edema.
LABORATORY DATA: Chest x-ray shows no acute infiltrate. Hemoglobin 10.8, white count 2.2, and platelets of 35. On admission, sodium 134, potassium 4.0, chloride 90, CO2 of 26, BUN 13, and creatinine 0.7. ALT and AST were elevated at 236 and 166 respectively.
IMPRESSION:
1. Hypotension, possible secondary to dehydration and/or sepsis.
2. History of head and neck carcinoma. Currently on chemotherapy with Taxotere, cisplatin, and 5-FU.
3. Bronchospasm.
4. Probable chronic obstructive pulmonary disease.
5. Status post percutaneous endoscopic gastrostomy.
6. Hypertension.
7. Hepatitis C.
8. Anxiety.
9. Hyponatremia.
RECOMMENDATIONS: Continue IV fluids. We will wean Neo-Synephrine as tolerated. Continue Merrem and vancomycin. We will place on respiratory treatment. Discontinue Aldactone and repeat labs in the morning.
