DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: PEG placement.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female who was admitted via the ER with altered mental status. Per the nursing home staff, the patient was found to have acute non-Q-wave MI and wants workup at the hospital. The patient has decreased p.o. intake and is refusing to eat. GI was consulted for PEG placement. The patient did have calorie counts done, which showed the patient to have decreased intake. Most of the history is obtained via chart review. The patient does have a history of dementia; however, the patient did deny any odynophagia or dysphagia.
PAST MEDICAL HISTORY: Hypothyroidism, renal failure, TIA, hypertension, gout, dementia, and hyperlipidemia.
PAST SURGICAL HISTORY: Cholecystectomy, hysterectomy, and PD catheter placement.
SOCIAL HISTORY: Nursing home patient. Negative for tobacco or ETOH abuse.
FAMILY HISTORY: Noncontributory.
MEDICATIONS: Allopurinol, Pacerone, aspirin, Plavix, folic acid, Synthroid, Niferex, and Protonix.
ALLERGIES: NKDA.
REVIEW OF SYSTEMS: Unable to obtain from the patient secondary to confusion.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.2, heart rate 74, respirations 18, and blood pressure 118/66.
LUNGS: Clear to auscultation.
HEART: Regular rate and rhythm.
ABDOMEN: Soft with positive bowel sounds, nontender.
NEUROLOGIC: The patient is awake and alert, but confused.
LABORATORY DATA: White blood cells 12.4, hemoglobin 10.2, hematocrit 31.4, MCV 102.8, platelet count of 272. Sodium 134, potassium 4.2, chloride 98, CO2 of 28, BUN 22, creatinine 3.4, calcium 8.8, and phosphorus 1.6.
IMPRESSION:
1. Decreased p.o. intake.
2. Non-Q-wave myocardial infarction.
3. End stage renal disease.
4. Transient ischemic attack/dementia.
PLAN: We will place the patient on Megace 40 mg p.o. t.i.d. and repeat calorie counts while the patient is on Megace and to see if there is any improvement. If no improvement, we will consider PEG placement. Due to the associated risks of bleeding and infection, we will do above. If no improvement, then questionable PEG.
