DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female who is nonverbal, who presents to the emergency department today from the nursing home. Apparently, the patient began spiking a fever to about 101 degrees at the nursing home today. She had been complaining of chest pain. She is having increasing secretions from her trach. She apparently does have a trach from multiple aspiration pneumonias and a difficult time coming off the ventilator. She does not eat anything. She has a G-tube secondary to severe GERD and difficulty tolerating p.o. She is not complaining of any abdominal pain. She is not short of breath, worse than normal. No history of dysuria or hematuria. Urine output has been normal. The patient’s daughter is present and actually helps provide the history. No evidence of diarrhea or history of diarrhea.
PAST MEDICAL HISTORY:
1. History of arrhythmia, status post pacemaker placement.
2. Multiple aspiration pneumonias.
3. Hypertension.
4. Gastroesophageal reflux disease.
5. Hypothyroidism.
PAST SURGICAL HISTORY:
1. Tracheostomy.
2. Pacemaker placement.
3. Spinal stimulator.
4. Colostomy.
ALLERGIES: NKDA.
SOCIAL HISTORY: The patient does reside at a nursing home.
REVIEW OF SYSTEMS: Unable to obtain secondary to the patient’s nonverbal status.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 36, pulse 72, respiratory rate 20, blood pressure 108/64, O2 sat 98% on trach collar. She is on 30% O2, which is what she is normally on at the nursing home.
HEENT: Head: Normocephalic and atraumatic. No lesions, masses noted. Eyes: Pupils are equal, round, and reactive to light. Conjunctivae and sclerae are clear, nonicteric. Oropharynx: Mucous membranes are moist and pink. No evidence of dehydration.
NECK: Supple, no JVD.
CHEST: Breath sounds are clear to auscultation bilaterally.
HEART: Regular rate and rhythm. No murmurs, thrills or gallops noted.
ABDOMEN: Soft. Multiple bruising noted on the abdomen. Nontender. There is a G-tube in place that appears to be functioning well with no surrounding erythema. There is a colostomy; patent and pink, productive.
EXTREMITIES: No obvious clubbing, cyanosis or peripheral edema.
DIAGNOSTIC AND LABORATORY DATA: EKG was obtained and revealed sinus rhythm at a rate of 72, PR interval 160, QRS 86, no acute ST elevation noted. Chest x-ray was obtained and reviewed. We did appreciate what appeared to be a left lower lobe infiltrate, new since previous examination. Also, question right distal basilar infiltrate as well. WBC 11.4, hemoglobin 12.4, hematocrit 37.6, and platelet count 398. PT 10.8, INR 1.04, PTT 27.36, glucose 108, sodium 132, potassium 4.2, chloride 96, CO2 of 31, BUN 22, creatinine 0.4, ionized calcium 1.14. Venous pH 7.42, CO2 of 45, bicarbonate 29, and lactic acid 1.8.
EMERGENCY DEPARTMENT TREATMENT AND COURSE: The patient was hemodynamically stable. We did go ahead and treat the patient for hospital-acquired pneumonia. She was given vancomycin, Zosyn, and Cipro after blood cultures were obtained. Sputum cultures were obtained. The patient remained stable.
CLINICAL IMPRESSION:
1. Left basilar hospital-acquired pneumonia.
2. Hypertension.
3. Status post tracheostomy.
4. Dehydration.
5. Spinal stenosis.
6. Hyponatremia.
DISPOSITION: The patient was admitted.
