DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Left lower lobe pneumonia and hypoxemia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male, ex-smoker, admitted for a fall and right humeral fracture. He is over one week out from an open reduction internal fixation of his right shoulder. Postoperatively, he has been fairly weak and bedridden and somewhat congested. A few days ago, he developed fever to 101.8. The patient has had chest radiographs that showed density in the left base suggestive of atelectasis versus infiltrate. He was noted to require oxygen up to 3 and 4 liters to maintain saturations in mid to low 90s. Ventilation-perfusion lung scan was obtained last evening, which showed some massive defects in the bases, most consistent with atelectasis, felt to be low probability thromboemboli. He has no history of the same. The patient’s cough has been somewhat feeble. He also has a history of dysphagia and prior problems with deglutition. He had a percutaneous endoscopic gastrostomy at one time for nutritional feeding. The patient has been cultured and started on intravenous Zosyn. White blood cell count yesterday was 13,300. Pulmonary consultation obtained now for further recommendations.
PAST MEDICAL HISTORY: As previously stated, he has dysphagia and deglutition difficulties. He is reportedly not known to have frank aspiration. He has not previously had a stroke per se, essential hypertension which is mild and he has had renal cell carcinoma resected. He also has a history of the carcinoma resected without recurrence. He has allergic rhinitis. He has prostatic hypertrophy. Rare bouts of atrial fibrillation and possible congestive heart failure. He has no anemia of chronic disease.
ALLERGIES: He has no known drug allergies.
PAST SURGICAL HISTORY: Prior percutaneous gastrostomy years ago. He has had renal cell carcinoma resected and colon cancer resected. He has had prostate biopsies and scrotal repair on this admission.
SOCIAL HISTORY: He is an ex-smoker. No occupational exposure. Normal alcohol consumption.
REVIEW OF SYSTEMS: Generally debilitated, somewhat dyspneic on mild exertion. He has a poorly productive cough, which is congested without hemoptysis. He has low-grade fevers without chills or rigors. Mildly dyspneic, but without chest pain. No diarrhea, dysuria, hematuria, skin rash, or leg pain. He is not noted to have thrombophlebitis or pulmonary emboli. Has some residual incisional pain in his right shoulder.
PHYSICAL EXAMINATION: Temperature is 98.6, pulse is 88, respiratory rate 34-40, and moderately labored. Blood pressure is 152/82. Oxygen saturation 96%. In general, he is a well-developed male, chronically ill, had mild dyspnea at rest. HEENT: Shows nontender sinuses. Nasal prongs in place. Oropharynx is clear. Neck reveals mild use of accessory muscles without jugular venous distention, bruits, or adenopathy. Lung fields have diminished breath sounds with few rhonchi in the left base. Heart examination is without gallop or murmur. Abdomen is soft, protuberant; otherwise benign. Healed percutaneous puncture site in the left upper quadrant. Genitourinary: Normal external male. Extremities: The right shoulder is in a sling. Incision is clean. Pneumatic compression hose in place. Negative Homans sign. No palpable cords. Neurologically, he is nonfocal.
IMPRESSION:
1. Status post open reduction internal fixation, right humeral fracture.
2. Left lower lobar atelectasis, postoperative.
3. Hypoxemia and fever secondary to left lower lobar atelectasis, rule out hospital-acquired pneumonia.
4. Currently low probability study for thromboemboli.
5. History of dysphagia and deglutition difficulty, rule out chronic aspiration.
RECOMMENDATIONS:
1. We will recommend albuterol with Mucomyst via IPPV q.i.d. and p.r.n.
2. Chest physiotherapy.
3. Pulse ox spot checks to maintain saturation 98% and better.
4. Venous Doppler of both lower extremities to rule out DVT.
5. Change low-dose IV heparin to Lovenox 3 mg subcu daily.
6. We will institute free water replacement for a recorded serum sodium of 152.
Thank you for this interesting consultation. We will continue to follow closely.
