DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Persistent mucopurulent bronchitis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with history of lung cancer, status post right upper lobectomy followed by radiation and chemotherapy, admitted with syncopal episode. She has had cough with purulent sputum. She has been on IV Zosyn and Diflucan without any improvement in her symptoms. She denies having any fever, chills, nausea, vomiting, diarrhea or dysuria. The patient is constipated.
PAST MEDICAL HISTORY: Significant for lung cancer followed by recurrence, history of pneumonia. She also had uterine cancer.
PAST SURGICAL HISTORY: Right upper lobectomy, hysterectomy, and lumbar laminectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient is currently on Zosyn, Diflucan, Protonix, prednisone, folic acid, Epogen, Lasix, and Mucinex.
SOCIAL HISTORY: History of smoking. The patient denies alcohol or drug use. She is divorced.
FAMILY HISTORY: Mother had lung cancer. Father had diabetes.
REVIEW OF SYSTEMS: As per HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98 degrees, pulse 88, respirations 20, and blood pressure 106/66.
HEENT: No oral thrush.
NECK: No lymphadenopathy.
LUNGS: Diffuse bilateral wheezing and rhonchi.
HEART: S1 and S2, regular rhythm.
ABDOMEN: Mildly distended. Mild discomfort. No rebound, guarding, or rigidity. Bowel sounds present.
EXTREMITIES: Superficial ecchymosis and skin tears.
NEUROLOGIC: No focal neurological deficits.
LABORATORY DATA: White count 5.2, hemoglobin 9.8, and platelets 262,000. BUN and creatinine 12 and 0.7. Sputum, gram-negative rod on smear. Previously, sputum had cultured Pseudomonas. Chest x-ray had shown retrocardiac air space disease.
IMPRESSION:
1. Persistent mucopurulent tracheobronchitis, previously cultured Pseudomonas.
2. History of lung cancer.
3. Skin tears.
RECOMMENDATIONS:
1. The patient has been on Zosyn for a while. We would switch her on to cefepime IV and inhaled TOBI, which is tobramycin via nebulizer.
2. Agree with her bronchoscopy.
Thank you, Dr. John Doe, for referring this patient to us.
