DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: For severe oxygen-dependent bronchospastic COPD.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female followed by Dr. Jane Doe for severe oxygen-dependent bronchospastic COPD. She was hospitalized in late November with an acute abdomen. Findings were consistent with acute appendicitis. She underwent laparoscopic lysis of adhesions, appendectomy, and drainage of a pericecal abscess at that time. She did well postoperatively. She was subsequently discharged and maintained on her normal pulmonary regimen. Over the last several days, she has had poor appetite. She has developed low-grade fevers and worsening lower abdominal pain. She presents to the emergency department today with CT scan showing a right lower quadrant abscess. She has been seen in consultation by Infectious Disease and pulmonary consultations have been requested. She is scheduled to undergo percutaneous drainage of the right lower quadrant abscess later today by Interventional Radiology. She denies nausea or vomiting. No diarrhea. She has had no significant cough until today when she developed some cough while in the emergency department. This was relieved with nebulization treatment.
PAST MEDICAL HISTORY: Significant for prior heavy smoking history. Quit more than 15 years ago. She has a history of diverticular disease and is status post colostomy and subsequent PEG done in the past. She has had hemorrhoidectomy in the past. No history of cancer, jaundice or hepatitis. She has a history of intermittent vertiginous symptoms for which she takes p.r.n. meclizine. History of osteoporosis and history of reflux disease.
MEDICATIONS: Synthroid, eye drops, nebulizer therapy, and oxygen.
ALLERGIES: NKDA.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Well documented in the previous chart.
PHYSICAL EXAMINATION:
GENERAL: An elderly female. She is alert and oriented. She is in no acute distress and nontoxic appearing.
VITAL SIGNS: Blood pressure is 154/64, pulse is 92 and regular, and respirations 18 and unlabored.
HEENT: Reveals sclerae anicteric. Oropharynx shows mucous membranes pink and moist.
NECK: Supple. Trachea is midline. No adenopathy appreciated in the supraclavicular or cervical region.
HEART: Exam reveals a regular rhythm. Normal S1 and S2. No gallop. No JVD.
LUNGS: Reveal decreased breath sounds. Coarse expiratory wheezes heard proximally as well as peripherally. No rale is audible.
ABDOMEN: Reveals healed scars from laparoscopy. There is moderate right lower quadrant tenderness to palpation and some rebound noted. No abdominal distention. Bowel sounds are decreased but present.
EXTREMITIES: Reveal no peripheral edema, clubbing or cyanosis.
NEUROLOGIC: Exam is nonfocal.
DIAGNOSTIC DATA: Chest x-ray shows hyperinflation. There is subtle infiltrative density in the right suprahilar region. This is similar to prior x-rays and followup of this area is warranted. She may need CT scan.
LABORATORY DATA: White blood count is 14,600, hemoglobin is 10.6, and platelet count is 412. Sodium 134, potassium 5.2, BUN is 9, and creatinine is 0.9. Urinalysis: Bacteriuria 1+. Arterial blood gases on 2 liters nasal cannula reveal pH 7.36, PCO2 of 48, and PO2 of 68.
IMPRESSION:
1. Severe oxygen-dependent chronic obstructive pulmonary disease, clinically stable.
2. Status post laparoscopic lysis of adhesions, appendectomy, and drainage of the pericecal abscess.
3. New right lower quadrant abscess on CT. This is likely the cause of her leukocytosis and fever, and she is scheduled for interventional radiology drainage today.
4. Questionable density in the right suprahilar region that requires additional evaluation, at least PA and lateral chest x-ray and possibly a CT scan of the chest is warranted in the future.
RECOMMENDATIONS: We agree with management as outlined. We will tend to the more immediate needs of perioperative pulmonary toilet for interventional radiology drainage as planned. She will be given oxygen nebulization and incentive spirometry. Antibiotics have been initiated with Zosyn and Flagyl, to be adjusted appropriately by Infectious Disease. Further decisions regarding evaluation of the right upper lobe density will be made thereafter.
