Transcript Continued

ACUTE SINUS INFECTION
11/03/2008
HISTORY: [patient] is seen on a work-in basis. She has a 4-5 day history of symptoms most
compatible with acute sinusitis manifested by some sinus tenderness, mucopurulent nasal
discharge.
PHYSICAL EXAMINATION
Blood pressure is 140/70, heart rate 108, respiratory rate 18, temperature 98.8, weight 119, up from
117.5. She is in no acute distress. She is well-dressed and well-groomed. She has nontender sinuses.
There is mild nasal obstruction, slight discharge, slightly discolored.
DATA
O2 sat 98%. EP and lateral chest x-ray shows no convincing evidence of acute change. She has some
mild biapical scarring.
DISCUSSION
I believe she has an acute sinus infection. We will treat this with Levaquin 750 mg 1 a day for 5 days, a
2-day sample provided. She may take a total of 7 days if nasal discharge remains mucopurulent or if
she continues to cough.
ADVANCED COPD
10/10/2010
PULMONARY FOLLOW UP VISIT
HISTORY OF PRESENT ILLNESS
The patient returns in followup for his advanced COPD status post lung volume reduction surgery at
[location] last year. In general, he has been doing well; although he remains slightly dyspneic with
activities of daily living.
PHYSICAL EXAMINATION
Vital Signs: Temperature 98.4, weight 78.2 kg, pulse 95, respirations 14, blood pressure 132/76, and O2
saturation 95% on room air. HEENT: Unremarkable. Chest: Distant breath sounds. Heart: Regular without
murmurs. Abdomen: Nontender. Neurologic: Normal. Extremities: There is no rash, cyanosis, clubbing, or
edema.
ASSESSMENT
The patient is doing well following his volume reduction. He continues on a good medication regimen for
COPD. He should get a flu shot this fall, and I am interested to see what his lung function has done since
typically the 3 to 6-month postoperative spirometry allows the best outcome with slow declines thereafter
associated with remodeling of emphysema. Therefore, …..
COMMON VARIABLE IMMUNODEFICIENCY
PULMONARY FOLLOW UP VISIT
10/09/2009
HISTORY OF PRESENT ILLNESS
The patient returns in followup of his common variable immunodeficiency with one month of chest
tightness and cough productive of green purulent sputum that has been gradually increasing over
the interval…..
PHYSICAL EXAMINATION
Temperature is 98.4, weight is 85.3 kg, pulse 117, height 74 inches, respirations 16, blood pressure 124/76,
and O2 saturation 96% on room air. HEENT: Unremarkable. He has no sinus tenderness or adenopathy. His
thyroid is of normal size. Chest: His chest…..
LABORATORY DATA
Laboratory evaluation today shows a quantitative IgG of 1515, which is a trough level for him after his
subcutaneous immunoglobulin infusion (Gammagard S/D 55 g weekly).
Because of his purulent sputum, today, I sent him for a chest CT without contrast that showed left lower
lobe bronchial wall thickening and bronchiectasis ….
ASSESSMENT
The patient has left lower lobe pneumonia on evaluation today that is the cause of his symptoms that have
been going on for one month. I told him…
ASTHMA AND SHORTNESS OF BREATH
PULMONARY FOLLOW UP VISIT
10/10/2010
HISTORY OF PRESENT ILLNESS
The patient returns in followup for her asthma and shortness of breath….
PHYSICAL EXAMINATION
Temperature is 98.8, weight is 83.9 kg, pulse 90, respirations is 17, blood pressure 121/56, O2 saturation
100% on room air. HEENT: Unremarkable. Lungs: Clear. Heart: Regular with her mechanical valve sounds
brisk. Abdomen: Nontender. Extremities: No rash, cyanosis, clubbing, or edema.
LABORATORY DATA
Spirometry today shows an FEV1 of 1.26 (70%), FVC equals 2.18 (95% of predicted), and DLCO equals 50% of
predicted. These values are almost identical to the values from March 7, 2009, when she was last seen, and
show no appreciable change in any of these values now that she is a nonsmoker.
ASSESSMENT
The patient has very mild COPD from her 36 years of cigarette smoking. Since she has ….
LEFT-SIDED BACTERIAL PNEUMONIA
11/05/2008
HISTORY
The patient is here to followup several problems. These are outlined in my consultation note dated
10/24/08 and by Dr. [name] discharge summary, 10/22 to 10/28/08. The patient completed his
course of antibiotics. He does not smoke, ….
PHYSICAL EXAMINATION
Blood pressure is 150/80, heart rate 71, respiratory rate 21, temperature 98.8, weight 187, height 5 feet 10
inches. He is in no acute distress. He has nontender sinuses, minimal if any nasal discharge and slight
obstruction. Oropharynx is clear. There is no JVD or stridor. TM's are mildly scarred. ….
DATA
O2 saturation 95%. Office EP and lateral chest x-ray shows resolution of the left basilar infiltrate/atelectasis.
DISCUSSION
I believe he had a left-sided bacterial pneumonia. This seems to have cleared. He will need a followup
evaluation here in 4 to 5 months with a non-contrast CT chest to followup very small right basilar nodules,
that are too small ….
MILD LEUKOPENIA
11/05/2008
HISTORY
The patient is here to followup several problems. He had mild leukopenia previously documented. He also has nonspecific anemia.
He had a colonoscopy within ….
PHYSICAL EXAMINATION
Blood pressure is 120/76, heart rate 77, respiratory rate 18, temperature 98.8, weight 166, up a
pound. He is in no acute distress…..
DATA
O2 saturation 94%. CBC today shows a normal white count of 5.7 but his anemia has worsened
a bit to a hematocrit of 36.6.
DISCUSSION
We will order B12, folate, reticulocytes, haptoglobin, S-PAP along with chemical profile and lipid
profile. He will call in a few days…
OBSTRUCTIVE SLEEP APNEA SYNDROME
11/05/2008
PROBLEMS
1. Obstructive sleep apnea syndrome.
a. Mild but symptomatic, AHI of 12.0, hypoxemia secondary to obstruction 87.2.
2. Periodic limb movements of sleep.
3. Restless leg syndrome.
4. Insomnia.
5. Allergy or intolerance to Requip, penicillin, and Z-Pak.
6. ….
HISTORY
The patient was last seen 05/09/09. She is using her CPAP 6 hours per night. She will often sleep through the night but will
have occasional periods where situational insomnia ….
PHYSICAL EXAMINATION
Blood pressure is 120/70, heart rate 90, respiratory rate 12, temperature 97.0, and weight 196, up a pound. She is welldressed, well-groomed and in no acute distress. She is awake and alert. There is no evidence of facial trauma due to CPAP
therapy. Sinuses are not tender. Nares are patent without discharge. Oropharynx is clear. TMs unremarkable. ….
DATA
O2 saturation 91%.
DISCUSSION
She is responding well to current therapies. She will intensify efforts at gradual weight reduction. She knows not to drive if
drowsy. She will ….
OSA SYNDROME
11/06/2008
PROBLEMS
1. Obstructive sleep apnea syndrome.
a. AHI 22.5.
1. Hypoxemia secondary to obstruction.
2. Mild allergic rhinitis.
3. For other diagnoses see prior records.
HISTORY
I last saw the patient 03/18/08. She is using nasal CPAP and uses it nightly. She will also use it
with occasional naps. She may get 4 to 5 hours of sleep utilizing CPAP. She still has some
difficulty with the straps, the device, etc., but she …
PHYSICAL EXAMINATION
Blood pressure is 120/80, heart rate 90, respiratory rate 15, temperature 98.4, weight 228, up from 198.
She is awake and alert. She has no evidence of facial trauma due to CPAP therapy. ….
DATA
O2 saturation 91%.
DISCUSSION
We have reviewed results for previous polysomnogram, CPAP titration. I have encouraged continued efforts
at compliance with CPAP both with sleep and with naps…..
POSSIBLE LUNG NODULES
11/04/2009
HISTORY
The patient is here for a brief followup of cough, nonproductive, and possible lung nodules on chest
x-ray 10/27/09. Refer to….
PHYSICAL EXAMINATION
Blood pressure is 120/70, heart rate 70, respiratory rate 19, temperature 98.2, ….
DATA
O2 saturation is 89%.
DISCUSSION
CT chest, noncontrast, was done today. This shows ….
ACUTE PNEUMONIA
11/06/2010
HISTORY
The patient is here to followup after a recent hospital stay. Refer to discharge summary 10/0 9 to
10/10/10 as done by Dr. [name] on behalf of Dr. [name]. Since discharge the patient has had three
different x-rays in Dr. [name]'s office. He told her that he thought the x-ray was back to baseline or
that the acute pneumonia had resolved. She has a history of bronchiectasis. She is not producing
mucopurulent sputum…..
PHYSICAL EXAMINATION
Blood pressure is 160/90, heart rate 97, respiratory rate 18, temperature 98, weight 171, height 5 feet 6
inches. She is well-dressed and well-groomed but appears younger than stated age. She has nontender
sinuses.
DATA
O2 saturation is 99% on room air.
DISCUSSION
I have reviewed the recent discharge summary as well as my consultation note 10/0710.
Clinically she is much improved. I do not believe additional antibiotics are needed now. She can use the
Albuterol 1 or 2 puffs every 4 hours as needed…..
BRONCHIAL ASTHMA
11/06/2010
HISTORY
She is here to follow up a number of problems including bronchial asthma, extrinsic, without recent
exacerbation, hyperlipidemia, hypertension, allergic rhinitis, obstructive sleep apnea syndrome, etc.
She has previously had pneumococcal vaccine……
PHYSICAL EXAMINATION
Blood pressure was 190/88 right arm seated, but home values or drug store values seem to be in the 140160/80-90 range on average. Heart rate is 90, respiratory rate 19, temperature 98.4. She had a brace on her
foot. Weight was deferred. She is in no acute distress. She appears younger than stated age. She has no
accessory muscle use. …..
DATA
Her O2 saturation is 97%, peak flow 340, a.m. lab work, chem. profile, lipid profile, etc., vitamin D level is
pending.
DISCUSSION
Clinically I believe she is doing well with the current problems…..
INTERSTITIAL LUNG DISEASE
PULMONARY FOLLOW UP VISIT
HISTORY OF PRESENT ILLNESS
The patient is here for followup for his diagnostic interstitial lung disease, probable NSIP versus atypical UIP, chronic renal
insufficiency and she does not want hemodialysis, mild obstructive sleep apnea followed by Dr. [name], moderate pulmonary
hypertension with last RVSP 59 to 67 which was improved from January 2009, GERD, and allergic rhinitis. …
PRESENT MEDICATIONS
Albuterol HFA 2 puffs p.r.n.; CPAP was 8 cm of water pressure; Nasacort 2 squirts q.a.m., she
does not really use; Coreg 25 mg p.o. daily; sodium bicarbonate 1300 mg p.o. b.i.d.; Prilosec 20
mg p.o. b.i.d.; Norvasc 10 mg p.o. daily; nitroglycerin 0.2 mg daily; Lipitor 40 mg p.o. nightly;
Lasix 40 mg p.o. daily; doxazosin 16 mg p.o. nightly; calcitriol 25 mg daily; ……
REVIEW OF SYSTEMS
Otherwise negative.
PHYSICAL EXAMINATION
A well-developed African-American female in no distress. I want to note she is 98 years old.
Temperature 97.9; weight 73 kg, down 3 kg since September 2008; pulse 68; respiratory rate 26;
blood pressure 184/84, repeated by myself was 174/74; and room air saturation 100%. HEENT:
Tympanic membranes are clear. Nares, marked turbinate edema and pale mucosa, right greater
than left. Oropharynx is clear. Neck: …..
CONTINUED
LABORATORY DATA
Today showed an iron level of 39; this is slightly improved from the previous iron level but significantly down from
2009 when the level was 76. Sodium 139, potassium 7.1, chloride 107, bicarbonate 25, BUN 55, and creatinine
2.9. That creatinine is improved from recently, from really the last three creatinines. GFR is 31, hemoglobin 9,
hematocrit 29.5; that is improved from the hemoglobin of 8.2. Last CT scan of the chest in May 2009 showed …
Pulmonary functions today, FVC 1.03 at 59% and FEV1 0.81 at 58% with a ratio of 79. The total lung capacity is 1.88 or 50%
of predicted. The diffusion capacity is 6.6 at 42% corrected for alveolar volume 106…..
ASSESSMENT
1.
Interstitial lung disease, NSIP versus atypical UIP.
2.
Bradycardia, improved.
3.
Chronic renal insufficiency, improved.
4.
Microcytic anemia, improved.
5.
Moderate pulmonary hypertension, last echo improved in previous discussion with [name]. There have been
no pulmonary artery hypotension medications but controlled volume status and blood pressure.
PLAN
Again, based on the patient’s age, risk of side effects for medications, risk of complications from a VATS biopsy which she
has repeatedly not wanted, I am going to keep her on the same medication regimen……
LUNG TRANSPLANT
10/20/2008
PULMONARY FOLLOW UP VISIT
HISTORY OF PRESENT ILLNESS
The patient returns in followup for her lung transplant evaluation. She was seen urgently last week because of abdominal pain that
lasted for 3 days and remains of unknown cause.
PHYSICAL EXAMINATION
Temperature 99.2, weight 96.1, pulse 110, respirations 19, blood pressure 144/66, and O2
saturation is 96% on room air. HEENT: Unremarkable. She has no adenopathy. Her chest has
basilar crackles of mild degree in both lungs. Heart: Regular. …..
ASSESSMENT
The patient’s new diagnosis of pancreatitis may explain some of her intermittent pain and how
brittle her diabetes has become. Whether this is an acute or chronic finding truly remains
unknown. Her amylase and lipase have been checked and are normal. Today, I checked a CMV
antibody titer to assure that this is not the effect of chronic infection, which returns negative.
The cysts in the head of the pancreas are likely benign; however, the gastroenterologist desires
to perform EBUS to aspirate these to assure that there is no malignancy here…..
ACUTE EXACERBATION OF COPD
HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE
This is a 54-year-old woman with a history of longstanding, very severe, chronic obstructive
pulmonary disease with frequent hospitalizations for acute exacerbations. Her most recent
hospitalization was April 17 through April 23 of this year. ….
She was admitted and treated with oral Zithromax …..
Her condition steadily improved. Her hospitalization ….
On day of discharge, she is comfortable with
Lab data prior to discharge included a fasting blood sugar ….
Spirometry showed a forced vital capacity of 2.62 L, which is 98% of predicted; and a 2-second forced vital
capacity of 960 mL, which is 59% of predicted. The FEV1 percent
The chest x-ray shows changes of COPD…..
The BUN is 13, creatinine 0.8, bicarbonate 26, hemoglobin 12.8, and white blood…..
DISCHARGE DIAGNOSES
1.
Acute exacerbation of severe chronic obstructive pulmonary disease.
2.
Steroid-induced…..
Continued
DISCHARGE INSTRUCTIONS
1.
She will be seen in my office in 4 months.
2.
She will see Dr. ***** in 1 month.
DISCHARGE MEDICATIONS
1.
Albuterol by hand-held nebulizer q.i.d.
2.
Cymbalta 20 mg daily.
3.
Singulair 12 mg nightly.
4.
Omeprazole 30 mg daily.
5.
Oxygen at 7 L per minute 24/7.
CELLULITIS AND CHEST PAIN
FINAL DIAGNOSES
1. Cellulitis, left leg.
2. Atypical chest pain.
DISCHARGE MEDICATIONS
1.
Levothyroxine 100 mcg daily.
2. Triamterene/hydrochlorothiazide 25 mg one-half tablet daily.
HISTORY OF PRESENT ILLNESS/HOSPITAL COURSE
The patient is an 89-year-old white female who presented to the hospital with some cellulitis on her left leg. She was started on IV antibiotics
and improved dramatically. She also had chest pain. She was seen in consultation by our cardiologists. They did not feel that she was having
typical angina. She underwent a stress Myoview GXT….
CHEST PAIN
FINAL DIAGNOSES
1.
Chest pain.
2.
Chronic obstructive pulmonary disease.
3. History of Bell palsy.
DISCHARGE MEDICATIONS
1.
Abilify 5 mg 1 or 2 at bedtime.
2.
Albuterol inhaler 2 puffs 4 times a day as needed for shortness of breath.
3.
Depakote 500 mg daily.
4.
Diclofenac 75 mg twice a day.
5.
Klonopin 1 mg 2 tablets twice daily as needed for anxiety.
6.
Lanoxin 0.25 mg daily.
HOSPITAL COURSE
The patient presented to the hospital with chest pain that sounded very suspicious for angina.
She was discharged ….