DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Respiratory failure.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old patient who is currently in the intensive care unit. He has undergone cardiac bypass surgery and currently he is on the ventilator. His most recent blood gas revealed a pH of 7.4 with pCO2 of 40 and pO2 of 168. He is on some low-dose nitroglycerin. He is currently down to 40% FiO2. His weaning from the ventilator is underway. His oxygenation seems adequate. He is beginning to wake up as well. He has a pacemaker in place from before with a history of atrial fibrillation and sick sinus syndrome.
PAST MEDICAL HISTORY: Coronary artery disease, sick sinus syndrome with history of atrial fibrillation and pacemaker in place, aortic regurgitation, hypertension, dyslipidemia, diabetes mellitus, and recent cardiac catheterization showing coronary artery disease necessitating cardiac bypass surgery.
PAST SURGICAL HISTORY: Cholecystectomy, hernia repair, transurethral resection of prostate, and pacemaker placement.
HOME MEDICATIONS: Benicar, Cardizem, potassium, digoxin, Proscar, Coumadin, Toprol, hydrochlorothiazide, Xalatan, and Lotrel.
ALLERGIES: NKDA.
FAMILY HISTORY: Positive for coronary artery disease.
SOCIAL HISTORY: No history of smoking or drinking currently.
REVIEW OF SYSTEMS: Cannot be obtained.
PHYSICAL EXAMINATION: Vital signs have been reviewed. Head was normocephalic. No evidence of trauma. Ears revealed no purulent discharge. Eyes showed the conjunctivae to be pink with no scleral jaundice. Nose had normal mucosa and septum. Neck was supple with no cervical or supraclavicular lymphadenopathy. Trachea was midline. Thyroid was not palpable. Respiratory examination showed normal symmetrical expansion of both hemithoraces. Coarse breath sounds with no wheezes or rhonchi. Heart had normal S1 and S2. No murmurs or gallops. Abdomen was soft and nontender. No organomegaly. Musculoskeletal examination revealed no swelling or effusion in any of the joints of the hands or feet. No peripheral edema. Skin examination revealed normal color, turgor, and temperature. No ulcerations or rash noted. Lymphatics revealed no cervical, supraclavicular or epitrochlear lymphadenopathy. Neurological examination was limited. He is currently intubated and sedated on a ventilator.
IMPRESSION:
1. Respiratory failure, intubated on the ventilator.
2. Possible dependent atelectasis.
3. Current ventilator setting, including 40% Fio2, PEEP of 5, and pressure support of 10.
4. Most recent blood gas showing pH of 7.4, pCO2 of 40, and pO2 of 168.
5. Status post cardiac bypass surgery.
6. History of pacemaker placement for sick sinus syndrome.
7. History of atrial fibrillation.
8. Hypertension.
9. Dyslipidemia.
10. Diabetes mellitus.
11. Advanced age.
RECOMMENDATIONS:
1. To continue to wean from the above ventilator or protocol. Once he is down to minimal setting, then we would like to obtain ABGs and mechanics to assess him for possible extubation.
2. Bronchodilator with albuterol 2.5 mg q. 4 hours as needed.
3. Following his extubation, he will need aggressive pulmonary toilet, including incentive spirometry.
4. Pain control.
5. Insomnia.
6. D-dimer and hemodynamics have been reviewed.
