DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female patient who, per report, had a nonsyncopal fall resulting in trauma to her face and head. In view of this, the patient was brought to the emergency room. Cervical spine revealed no fracture but severe spinal stenosis with cord impingement at C4-C5 as well as C5-C6 with possible compression on this area. She also had plain films of the pelvis that showed a lucent lesion with sclerotic margins in the right femoral neck. Chest x-ray revealed the presence of a right hilar fullness, possible mass, as well as right upper lobe infiltrate. CT of the maxillofacial showed multiple periosteal disease involving the maxillary sinus and a nondisplaced fracture involving the lateral wall of the left maxillary sinus. Scalp hematoma on the left frontal region. Abnormal soft tissue density in the posterior left lobe, which could represent hemorrhage or neoplasm. Orbital floor was poorly evaluated. Presently, the patient is confused and a very poor historian, but she is alert and agitated. We have been consulted for evaluation and management of her abnormal chest x-ray.
PAST MEDICAL HISTORY: Significant for dementia. The patient has had a history of diabetes mellitus. She has had a history of chronic obstructive pulmonary disease as well as irritable bowel syndrome. She has had a history of hypothyroidism, history of previous sinusitis and transient ischemic attack in the past. She has had a history of breast cancer on the left as well as spinal stenosis, history of degenerative joint disease, history of frontal hygroma, recent TIA in the past. She has a history of hypertension.
PAST SURGICAL HISTORY: She has had previous left mastectomy, tonsillectomy, cholecystectomy, appendectomy, and lipoma surgery.
MEDICATIONS: She has been on regular insulin sliding scale, Seroquel, Glucotrol, Zyrtec, Advair, Lasix, Tylenol, Diovan, verapamil, Celexa, levothyroxine, Depakote, Hemocyte, Ativan, DuoNeb and Robitussin.
ALLERGIES: MULTIPLE DRUG ALLERGIES.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: This patient lives in an extended care facility.
REVIEW OF SYSTEMS: Unable to be obtained as the patient is confused but alert.
PHYSICAL EXAMINATION: Temperature 98.4, pulse 96, respiratory rate 18 and blood pressure 136/66. She is an elderly lady, in no acute distress at the moment of my evaluation. HEENT revealed hematoma over the left orbit. No active bleeding. Eyes with anicteric sclerae. No active bleeding from the eyes. No evidence of jugular venous distention. Trachea was in the midline. Heart exam was regular rate and rhythm without any appreciable gallops or rubs. Lung sounds are symmetrical bilaterally without excursion. No use of any accessory muscles of respiration. No dullness to percussion. There were some mild occasional rhonchi and increased expiratory phase. Abdominal exam was benign. Bowel sounds normoactive. Extremity exam with trace lower extremity edema but no cyanosis. No venous cords were palpated. The patient was moving all 4 extremities. Neurologically, she is alert but confused.
DIAGNOSTIC DATA: An electrocardiogram showed normal sinus rhythm at a rate of 96, possible left atrial enlargement, borderline low voltage in the frontal leads, probable anteroseptal MI.
LABORATORY DATA: White blood cell count 9.4, hemoglobin 10, platelet count 286. Sodium 146, potassium 4.2, chloride 106, CO2 of 30, glucose 104, BUN 54, creatinine 1.3, calcium 9.6. UA showed 0 to 4 red blood cells, 0 to 4 white blood cells.
IMPRESSION:
1. Status post nonsyncopal fall resulting in facial fracture as outlined above.
2. Cervical spine showing spinal stenosis as well as cord impingement, possible compression at the level of C4 to C6.
3. Abnormal chest x-ray with the presence of a right perihilar mass-like density as well as a right upper lobe infiltrate. Question whether the patient has aspiration pneumonitis.
PLAN:
1. The patient has been pancultured. Continue with Avelox for now.
2. CT of the chest without contrast will be obtained.
3. Ophthalmologist will be asked to make maxillofacial surgery consultation.
4. An x-ray Doppler of the lower extremities will be obtained to rule out DVT.
5. Bronchodilator therapy with a DuoNeb q.i.d.
6. Further recommendations will be based on clinical course.
