DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Evaluation for acute respiratory insufficiency.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who was brought to the emergency department with complaint of difficulty breathing, weakness, and progressive shortness of breath over a period of two months. The patient has also been complaining of a nonproductive cough. She denies any chest pain, and upon evaluation in the emergency department, the patient was in atrial fibrillation, but the rate was controlled. Oxygen saturation on 2 liters nasal canula was 89%. Laboratory exam revealed digoxin toxicity and leukocytosis along with renal insufficiency. Chest x-ray showed mild perivascular congestion, old granulomatous disease, and left lower lobe fibrosis. The patient was placed on Rocephin and DuoNeb, however has developed tachyarrhythmia. She was also given Lasix 60 mg last night and has been placed on 40 mg b.i.d. ABG performed last night showed a significant degree of respiratory acidosis. Since that was taken, the patient had significant diuresis. Her breathing has improved. A pulmonary consultation has been requested.
PAST MEDICAL HISTORY: COPD, pneumonia, atrial fibrillation, diastolic noncompliance with ejection fraction of 65%, hypothyroidism, hypertension, diabetes, chronic renal insufficiency, and hyperlipidemia.
PAST SURGICAL HISTORY: Appendectomy.
ALLERGIES: No known drug allergies.
HOME MEDICATIONS: Synthroid, Hyzaar, Cardizem XT, digoxin, Coumadin, lisinopril, Zocor, Avandia, iron, and albuterol nebulizers.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: The patient lives with her family. She has a history of smoking. She denies any alcohol consumption.
REVIEW OF SYSTEMS: The patient denies any chest pain. She complains of weakness. She did have severe shortness of breath last night with some improvement today. Her cough is generally nonproductive. She denies any nausea, vomiting or diarrhea. She has occasional leg swelling. She denies any neurological or motor or sensory changes.
PHYSICAL EXAMINATION:
GENERAL: The patient is awake.
VITAL SIGNS: Oxygen saturation is 97% on 4 liters. Temperature is 97.4 degrees with a pulse of 56, respiratory rate of 24, and blood pressure of 154/52.
HEENT: Head shows no evidence of trauma. Sclerae nonicteric. Conjunctivae are pink. Mucous membranes are moist.
NECK: Supple. Trachea is midline. There is no JVD noted.
HEART: Regular rate and rhythm. There is normal S1 and S2 with no murmurs.
LUNGS: Revealed diminished breath sounds with inspiratory crackles heard in both lung bases. There is slight expiratory wheezing. The respirations are shallow, and there is poor air entry.
ABDOMEN: The abdomen soft, nontender with normoactive bowel sounds.
EXTREMITIES: Show trace edema. There is no clubbing or cyanosis.
NEUROLOGIC: The neurologic exam shows no focality.
DIAGNOSTIC STUDIES: Chest x-ray shows diffuse interstitial opacities along with calcified nodules scattered throughout the right lung. These are unchanged from previous x-rays. She has got a left lower lobe parenchymal fibrosis causing retraction of the left hemidiaphragm. CT angiogram shows no evidence of pulmonary embolism. She has small bilateral effusions with noncalcified nodules in the left lower lobe, mild infiltrates in the right upper and right lower lobe.
LABORATORY DATA: The patient’s serum sodium is 138 with potassium of 5, chloride of 102, carbon dioxide of 30, glucose 172, BUN of 30, and creatinine 1.2. White count is 12,800, hemoglobin of 12.4, hematocrit of 38.2, platelet count 328. PT 24.6 with an INR of 2.21. Arterial blood gas obtained at midnight showed a pH of 7.10 with a pCO2 of 112, pO2 of 66, oxygen saturation of 83%.
DIAGNOSTIC IMPRESSION:
1. Respiratory insufficiency secondary to congestive heart failure complicated by the possibility of pneumonia. We suspect that mostly chest x-ray findings represent fluid retention. The patient, however, will empirically be placed on antibiotics until further evaluation can be performed.
2. The patient has pulmonary nodules. The patient does have a history of granulomatous lung disease. These are mentioned on previous CTs and chest x-rays.
3. Mild leukocytosis.
4. Atrial fibrillation, on anticoagulation therapy.
PLAN:
1. Change nebulizers to Xopenex because of tachyarrhythmia.
2. Solu-Medrol 60 mg IV push q. 8 hours.
3. Rocephin 1 gram IV piggyback daily.
4. Repeat ABG.
