SUBJECTIVE: The patient comes in for a followup appointment. He is an (XX)-year-old Hispanic male with a past medical history of CAD, mild ischemic cardiomyopathy, hypertension, prostate CA, angina, and shingles. He is complaining of right-sided chest pain, which is much worse when he takes deep inspiration. He denies nausea, vomiting, fever, chills, GI, or GU complaints. He does not have retrosternal pain.
CURRENT MEDICATIONS: Duragesic patch 25 mcg; Imdur 60 mg, one in the a.m. and half in the p.m.; Zocor 40 mg; Toprol-XL 50 mg; Altace 10 mg; Zyrtec 10 mg; nitroglycerin p.r.n.; quinine p.r.n.; Prevacid 30 mg; Niaspan 500 mg at bedtime; Ultracet b.i.d. p.r.n.; Actonel 35 every week; and Norvasc 5 mg.
ALLERGIES: No known drug allergies.
OBJECTIVE:
VITAL SIGNS: T: 98.4. P: 86. R: 26. WT: 144. BP: 126/62.
HEENT: Normocephalic, atraumatic. PERRLA. No icterus or conjunctival inflammation. TMs clear bilaterally. Nasal mucosa pink, no exudate. Oropharyngeal mucosa normal. No lesions or exudates.
NECK: Supple. No JVD, adenopathy, or bruits.
LUNGS: Clear to auscultation bilaterally.
HEART: S1, S2, RRR.
ABDOMEN: Soft, nontender, positive bowel sounds.
EXTREMITIES: No clubbing, cyanosis, or edema.
ASSESSMENT AND PLAN: We will do CBC, Chem, sedimentation rate, and a D-dimer today. The patient will be set up for the morning to get a CT of the chest with PE protocol with half the usual dose given his age and mild cardiomyopathy. In the meantime, we will treat the pain with a Lidoderm patch. We have instructed his wife on how to use it and also get some T-spine films. We have discussed the differential diagnoses, includes pleurisy, pulmonary embolic phenomenon, recurrence of shingles or a T-spine compression fracture with radiating pain to the right hemithorax. Since there is not so much abdominal pain, intra-abdominal process is less likely. We will see the patient again in one week. We have instructed the wife to call us immediately if he does have appearance of the classic rash of shingles.
DIAGNOSES:
1. Right pleuritic pain.
2. Ischemic cardiomyopathy.
3. History of shingles.
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SUBJECTIVE: The patient has been coughing, short of breath since Thursday. She said she got it flared up by someone’s perfume. She was better on Friday. Today, she is worse again, took some Depo-Medrol 160 mg today. She is coughing. She has no productive phlegm. She has tightness in her chest, and she took some Vantin 200 mg twice a day for 4 days, doxycycline 200 mg twice a day. She was not put on any oral steroids. Her peak expiratory flow rates at home have been greater than 250.
OBJECTIVE: On exam today, the patient is coughing, dyspneic. Blood pressure is pending. Respiratory rate 24. Saturations on room air 98%. HEENT: She has no lesions or thrush. Neck is supple without adenopathy. Lungs: She has mildly decreased breath sounds with an expiratory wheeze. She is moving fairly good air. She has increased respiratory effort. Abdomen: Benign. Extremities: No edema.
ASSESSMENT: She has status asthmaticus with cough. It was secondary to her underlying asthma, allergic symptoms, and a prolonged QT.
PLAN: The patient needs Vantin, which she will continue for 6 more days. She needs to go home. Her peak expiratory flow in the office was 400 pre-bronchodilator. She is taking a treatment right now. We gave her prednisone burst and taper. We will see her back next week. If her symptoms worsen or she does not improve, she needs to go to the emergency room. The patient understands that.
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SUBJECTIVE: This pleasant (XX)-year-old gentleman unfortunately continues to experience dyspnea with low levels of activity. He continues to participate in pulmonary rehab and appears to be very compliant with his medications and involved in his care. Reviewing his prior CT scan of the thorax, unfortunately, there was considerable pulmonary disease that we may not be able to do anything about.
OBJECTIVE: Weight is stable at 204 pounds. Saturations on room air 95% at rest. Pulse is 75 per minute. Respiratory rate of 24 per minute. Blood pressure is 124/72. Head and Neck: There is no evidence of supraclavicular adenopathy. Heart: Regular. Lungs: Diminished breath sounds but no significant wheeze. Extremities: Demonstrate no cyanosis, clubbing, or edema.
ASSESSMENT: Advanced underlying chronic obstructive pulmonary disease and emphysema with chronic dyspnea with exertion.
PLAN: At this point in time, we would like to start Spiriva one capsule daily. He is not to use his Combivent while he is on this. We have provided him with a Proventil HFA. He will receive a prescription for Spiriva and Proventil. We would like to see him once again in 4 weeks to see how he is doing. He should continue with his Advair 100/50 mcg. We will see him once again and comment further with regards to changes in his regimen after next visit.
