DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Dyspnea and pneumonia.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic male who has a history of chronic obstructive pulmonary disease and lung cancer, who was admitted through the emergency department with increasing chest congestion, shortness of breath, and cough. Chest x-ray showed low lung volume, elevated left hemidiaphragm, and opacity in the upper lobe area. The patient has been admitted for community-acquired pneumonia.
PAST MEDICAL HISTORY: Lung cancer, status post radiation treatment. According to previous record, the patient was having some involvement of the right main bronchus. Chronic obstructive pulmonary disease, chronic O2 dependent. The patient was seen by a pulmonologist before. History of seizure disorder, history of Bell’s palsy, anemia, status post bilateral knee replacement.
ALLERGIES: PENICILLIN.
CURRENT MEDICATIONS: Reviewed and very well documented in the chart.
SOCIAL HISTORY: Positive for smoking two to three packs per day. He quit smoking three years ago. He smoked almost 35 years. He is mainly wheelchair bound. He sometimes walks with help and walker.
REVIEW OF SYSTEMS: As in history of present illness. The patient is not a good historian and cannot give a good review of system. Previous record also reviewed.
PHYSICAL EXAMINATION:
GENERAL: The patient is comfortable, in no acute respiratory distress.
VITAL SIGNS: Blood pressure 132/54, respirations 20, pulse 64, and he is afebrile. Pulse oximetry is 98% on 2 liters.
HEENT: Sclerae nonicteric. Conjunctivae pink. The patient has ptosis of the left eyelid.
NECK: No mass. No lymphadenopathy.
CHEST: Bilateral rhonchi. Decreased air exchange, especially at the lower part of the chest.
HEART: S1 and S2 audible. Regular rate and rhythm.
ABDOMEN: Soft, nondistended, and nontender.
EXTREMITIES: No edema. No clubbing. No cyanosis.
LABORATORY DATA: Laboratory work showed WBC count of 8.8, hemoglobin 10.2, and platelets of 290. Sodium 142, potassium 4.2, BUN is 9, and creatinine is 0.8. Liver function test is normal. Arterial blood gases showed pH of 7.38, PCO2 of 58, and PO2 of 70.
DIAGNOSTIC DATA: The patient also had a CT of the head performed, and it did not show acute process. There was generalized atrophy with small vessel ischemic changes. We are not totally clear as to why CT of the head was ordered. Chest x-ray reviewed. Previous record also reviewed. His last CT of the chest was performed six months ago and showed consolidation involving upper lobes and right lower lobe. There was a small bilateral pleural effusion at that time. No pulmonary embolism.
The patient denies any chest pain or hemoptysis.
IMPRESSION: The patient is a (XX)-year-old male with a history of lung cancer, advanced chronic obstructive pulmonary disease, heavy smoking history in the past, O2 dependent. The presentation is consistent with pneumonia.
RECOMMENDATIONS: Continue IV antibiotic for community-acquired pneumonia protocol. It may be reasonable to perform a swallowing evaluation to make sure there is no element of aspiration. The patient had pneumonia with upper lobe involvement six months ago. We will repeat CT of the chest also for followup.
