DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Failure to thrive.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with multiple medical problems admitted for UTI and left lower lobe pneumonia, requested to be seen for evaluation of PEG tube placement for failure to thrive for the past two months with only 10-15% of overall intake. The patient denies any nausea, vomiting, abdominal pain or change in bowel habits.
PAST MEDICAL HISTORY: Significant for coronary artery disease, diabetes mellitus, diabetic neuropathy, retinopathy, colon cancer in the remote past, hypertension, dyslipidemia, peptic ulcer disease, congestive heart failure, ureteral stones, and diverticulosis.
PAST SURGICAL HISTORY: Significant for coronary artery bypass surgery, nephrostomy with ureteral stent placement, right thoracocentesis, and rotator cuff injection treatments.
MEDICATIONS: In hospital include insulin, Reglan, doxycycline, Lipitor, isosorbide mononitrate, Zestril, Protonix, Coreg, Megace, Lovenox, Zosyn, and multivitamin.
ALLERGIES: MULTIPLE MEDICATION ALLERGIES, LISTED IN THE CHART.
SOCIAL HISTORY: No history of smoking, alcohol or drug use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: A 12-point review of systems is essentially unremarkable, except as per HPI.
PHYSICAL EXAMINATION:
VITAL SIGNS: Pulse 78, blood pressure 118/48, afebrile, and respiratory rate 26.
HEENT: Examination shows no pallor. No icterus. Dry pink oral mucosa.
NECK: Supple. No JVD. No adenopathy.
CHEST: Clear to auscultation.
HEART: Heart sounds, regular rate and rhythm. S1, S2.
ABDOMEN: Soft. Mild lower abdominal tenderness, multiple scars noted. Bowel sounds positive.
RECTAL: Exam was deferred.
EXTREMITIES: No cyanosis, clubbing or edema.
NEUROLOGIC: Exam nonfocal.
LABORATORY DATA: WBC 10.8, hemoglobin 10.2, hematocrit 30.6, and platelets of 176,000. Basic metabolic profile significant for glucose 142, BUN 24, and creatinine 0.8. LFTs are normal.
IMPRESSION:
1. Failure to thrive.
2. Pneumonia/urinary tract infection.
3. Diabetes mellitus.
4. Coronary artery disease/congestive heart failure.
PLAN: Recommend supportive care. Continue enteral feeding through Dobhoff. Attempt EGD with PEG placement in the a.m. Discussed case, with the risks and benefits, with the patient and the patient’s daughter.
Thank you very much for allowing us to participate in taking care of this patient.
