DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: A male with chronic steroid-dependent asthma and sciatica with surgery scheduled in a couple of days.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male with a long-standing history of asthma since childhood. He did improve and seemed to clear at high school. He was then stable until about 4 to 8 years ago when he again began to have some flaring of the asthma off and on. He was placed on prednisone, which has been very helpful. Attempts to wean him off prednisone have been unsuccessful. He also had been on Theo-Dur for a while, which was stopped years ago. He currently is on daily prednisone 5 mg a day. He still has some intermittent flaring and also uses a nebulizer. More recently, he was evaluated and was noted to have continued wheezing and was bumped on the steroids to 20 mg daily for the past few days. He was also placed on Advair 250/50 twice a day and Singulair 10 mg daily. On this regimen, he has felt symptomatically much improved and has not required the use of his nebulizer.
He has had intermittent sinusitis as well in the past, which tends to flare when his asthma flares. He had previously been on nasal sprays about 4 to 8 years ago but has not used this recently. He does not know what factors trigger his asthma. He has been hospitalized in the past frequently for his asthma but not recently. He does not have any active cough, sputum production, hemoptysis, chest pain, shortness of breath, fever, chills, or night sweats. He has had chronic back pain. About (XX) years ago, he injured his back while at work, lifting heavy objects. He had surgery at that time and then was fine for a while. He then again suddenly developed back pain about a month ago and had pain going down to his right leg. He was evaluated and was found to have narrowing of the spinal canal, herniated disk, as well as spurs. He was, therefore, felt to be a candidate for surgery, which is scheduled. Because of his significant wheezing earlier, he was referred for pulmonary evaluation and clearance for his anticipated surgery.
He did have pulmonary function testing done as an outpatient in the office, which was significantly abnormal with an FEV1 of 1.26 L (33% of predicted) and FEV1/FVC ratio of 50%. At that time, he was actively wheezing. He has had chest x-rays done in the past but does not recall when the most recent one was done. He, therefore, had a chest x-ray done today.
PAST MEDICAL HISTORY: Includes an allergic reaction to an unknown medication with increased shortness of breath and wheezing. He was observed without problems. He has a history of diabetes and gout. He has history of chronic asthma, sinusitis, and bronchitis in the past. He has no history of hypertension, heart disease, ulcers, reflux, thyroid disease, liver disease, kidney disease, or hyperlipidemia.
SOCIAL HISTORY: He does not work with asbestos. He has been a chronic smoker averaging 1 pack of cigarettes per day for 30 years. He denies a chronic smoker’s cough. He does not drink alcohol. He drinks 3 cups of coffee daily.
ALLERGIES: TO AN UNKNOWN MEDICATION.
FAMILY HISTORY: Mother died from complications of diabetes and a heart attack. Father is in good health. He has 3 sisters in good health. He has 3 daughters in good health.
MEDICATIONS: Prednisone 20 mg daily, Advair 500/50 mcg twice a day, Singulair 10 mg daily, albuterol inhaler 2 puffs every 4 hours as needed, nebulizer with albuterol solution as needed, Glucovance 5/500 mg twice a day, Lyrica 75 mg 2 twice a day, oxycodone 5 mg 4 times a day, and OxyContin 40 mg 1 twice a day.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is a well-developed, well-nourished, mildly obese male in no acute distress. He was alert and cooperative.
VITAL SIGNS: Temperature 97.4, pulse 86 per minute, respirations 18 breaths per minute, blood pressure 148/80, and O2 saturation 94% on room air.
HEENT: Normocephalic. No scleral icterus. No sinus tenderness. No nasal obstruction. Pharynx was noninjected but slightly narrowed.
NECK: There was slight neck adiposity. No neck vein distention, thyroid enlargement, or lymphadenopathy.
CHEST: No chest wall tenderness. Expansion was symmetrical.
LUNGS: Lung fields were clear initially. When he lay supine, there was mild wheezing anteriorly, which continued when he sat up. Breathing was not labored, however, and there were no retractions.
HEART: Regular rate. Normal S1 and S2. No murmurs.
ABDOMEN: Obese with no masses, tenderness, or organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. There were some scattered hyperpigmented changes on his lower extremities and slight venous varicosities but no phlebitis.
DIAGNOSTIC DATA: Chest x-ray revealed borderline cardiomegaly, slight prominence of the bronchovascular markings. No acute infiltrates or effusions or congestion was noted. Spirometry: FVC 3.50 L (75% of predicted) FEV1 2.53 L (67% of predicted), FEV1/FVC 72%, FEF 25-75 1.76 L/sec (45% of predicted).
INTERPRETATION: These findings are consistent with mild obstructive ventilatory impairment consistent with chronic obstructive pulmonary disease due to asthma, bronchitis, emphysema, or bronchiolitis. There had been a significant improvement compared to a previous study, when the FEV1 was 1.26 L (33% of predicted) and FVC was 2.51 L (51% of predicted).
ASSESSMENT: Steroid-dependent asthma, which has significantly improved on increasing prednisone and addition of Advair and Singulair to his regimen. This was done in the past week with marked improvement in his pulmonary function studies. He feels symptomatically much improved. He also is somewhat chronically overweight and has history of snoring and partial upper airways obstruction with possibly a component of occult sleep apnea. He has diabetes. He had previous degenerative disk disease and had surgery. He now has recurrence of severe back pain with sciatica, and the pain is going down to his right leg. He is scheduled for surgery in the next couple of days. At this time, he appears to be clinically stable on the higher dose of prednisone and adjustment of his medications. He also has allergic rhinitis, which has been relatively stable.
RECOMMENDATIONS: He is medically stable at this time and cleared for surgery. We will continue his medical regimen. He will need steroid prep at the time of surgery and his steroids can later be tapered following surgery. Updraft treatments with albuterol and Atrovent can be initiated during his perioperative course. We would continue with the Advair and Singulair, which has helped along with his prednisone. He will be monitored for sleep-associated desaturation or additional symptoms and may benefit in the future from a sleep study to rule out obstructive sleep apnea. He has been encouraged to stop smoking cigarettes. He has also been encouraged to begin a diet and exercise program to control his weight and improve his overall conditioning.
Thank you for the opportunity of participating in the management of this patient.
