DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Tracheobronchitis and increased respiratory secretions.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old Hispanic gentleman. The patient states that he is a lifelong nonsmoker. He is quite alert. The patient is noted to have a history of obstructive sleep apnea, details unknown, as well as a history of colon cancer, osteoporosis, prostate cancer, paranoid schizophrenia, gastroesophageal reflux disease, asthma, and pneumonia. According to the chart, the patient has had previous right hemicolectomy, previous surgery for olecranon bursitis, prostatectomy, and left cataract surgery.
MEDICATIONS: The patient is currently on intravenous Zosyn 3.375 g every 6 hours. The patient is also receiving Protonix; Zyprexa; ferrous sulfate; Zoloft; Pravachol; prednisone 20 mg a day; montelukast 10 mg once a day; metoprolol 25 mg twice a day; and furosemide 40 mg per day.
FAMILY HISTORY: Noncontributory to this particular case.
REVIEW OF SYSTEMS: The patient denies any hemoptysis, nausea or vomiting. The patient has had a swallowing study during this hospitalization, and he has been receiving dysphagia therapy. The patient is noted to have pharyngeal stasis due to backflow from his esophagus, but he is tolerating pureed diet with thin liquids. ENT has also been consulted, and this evaluation is pending. The patient has been noted to have very thick secretions.
PHYSICAL EXAMINATION:
GENERAL: The patient is in no acute distress, but when he coughs, you can hear the secretions rattling in his upper airways.
VITAL SIGNS: He is afebrile with a pulse of 94; respiratory rate 16; on 2 liters, he is 97%; blood pressure 118/64.
NECK: Supple. Trachea is midline. There is no stridor.
CHEST: Scattered rhonchi, rare scattered expiratory wheezes.
CARDIAC: S1, S2.
ABDOMEN: Soft, nontender.
EXTREMITIES: Without edema.
The patient has been seen by Physical Therapy but is felt to be at his functional baseline. He has difficulty getting out of bed into the chair.
DIAGNOSTIC DATA: The patient’s chest x-ray was reviewed. There is elevation of the right hemidiaphragm. This is a portable AP film with no interval change compared with two years ago. The patient is being followed closely by Infectious Disease.
LABORATORY DATA: The patient’s laboratory data includes a white count of 17.6, hematocrit 35.2, and platelet count of 298,000. Serum bicarbonate today is up to 36 from 34 yesterday, creatinine today is 1.4, and potassium 4.5. Blood cultures and urine cultures from admission showed no growth at this time.
IMPRESSION AND PLAN: Tracheobronchitis. At this point, we do not have culture data to guide us, but the patient is on appropriate broad-spectrum antibiotics. Swallowing status has been assessed as mentioned above. We would like to further assess this issue of esophageal backflow by obtaining a barium swallow/upper GI, and we would also like to clarify the patient’s left ventricular function by obtaining an echocardiogram. If the patient does not need diuretic therapy, this might help his respiratory status as the diuretics could be drying out his secretions. In addition, we are not sure if the patient may have contraction alkalosis related to his loop diuretic therapy. His serum bicarbonate is elevated. We will check ABG to clarify his acid base status. We will obtain followup chest x-ray. We will keep oxygen humidifier to mobilize secretions. We will start Lovenox 40 mg subcutaneously every 24 hours for DVT prevention. We will also start long-acting beta-agonist with Foradil one capsule inhaled twice a day as well as DuoNeb with Accupril every 4 hours while awake and as needed. We have authorized respiratory therapist to suction the patient on an as-needed basis, and we will also start guaifenesin 1200 mg twice a day. We would recommend clarification of this patient’s code status in light of his advanced age and multiple comorbidities. He could certainly develop mucus plugging and rapid respiratory decompensation. We will await the ENT evaluation with interest.
