Negative for diaphoresis and chills.
Negative for diaphoresis and chills.
Clinical Scenario:
REASON FOR CONSULTATION: Desaturation to 64% on room air 1 hours ago with associated shortness of breath.
HISTORY OF PRESENT ILLNESS: Mrs. X is 73-year-old Caucasian female who was admitted to the general surgery service 3 days ago for a leaking j-tube which was surgically replaced 2 days ago and is now working properly. This morning at 07:30, the RN reported that the patient was sleeping and doing fine, then the CNA made rounds at 0900 and Mrs. X was found be mildly dyspneic. Vital signs were checked at that time and were; temperature 38.6, pulse 120, respirations 22, blood pressure 138/38. O2 sat was 64% on room air. The general surgeon was notified by the nursing staff of the hypoxia, an order for a chest x-ray and oxygen therapy were given to the RN. The O2 sat is maintaining at 91% on 4L NC. The patient was seen and examined at 10:10 a.m. She reports that she has been having mild dyspnea for 2 days that has progressively gotten worse. She does not use oxygen at home. Her respiratory rate at the time of visit was 22 and she feels short of breath. She has felt this way in the past when she had pneumonia. She is currently undergoing radiation treatment for laryngeal cancer and her last treatment was 1 to 2 weeks ago. She reports that she has 2 to 3 treatments left. She denies any chest pain at this time and denies any previous history of CHF. Review of her vital signs show that she has been having intermittent fevers since yesterday morning. Of note, she was admitted to the hospital 3 weeks ago for an atrial fibrillation with RVR for which she was cardioverted and has not had any further problems. The cardiologist at that time said that she did not need any anticoagulation unless she reverted back into A-fib.
REVIEW OF SYSTEMS:
Constitutional: Negative for diaphoresis and chills. Positive for fever and fatigue.
HEENT: Negative for hearing loss, ear pain, nose bleeds, tinnitus. Positive for throat pain secondary to her laryngeal cancer.
Eyes: Negative for blurred vision, double vision, photophobia, discharge or redness.
Respiratory: Positive for cough and shortness of breath. Negative for hemoptysis and wheezing.
Cardiovascular: Negative for chest pain, palpitations, orthopnea, leg swelling or PND.
Gastrointestinal: Negative for heartburn, nausea, vomiting, abdominal pain, diarrhea, constipation, blood in stool or melena.
Genitourinary: Negative for dysuria, urgency, frequency, hematuria and flank pain.
Musculoskeletal: Negative for myalgias, back pain and falls.
Skin: Negative for itching and rash.
Neurological: Negative for dizziness, tingling, tremors, sensory changes, speech changes.
Endocrine/hematologic/allergies: Negative for environmental allergies or polydipsia. Does not bruise or bleed easily.
Psychiatric: Negative for depression, hallucinations and memory loss.
PAST MEDICAL HISTORY:
Diabetes mellitus that was diagnosed 12 years ago with neuropathy. This resolved after gastric bypass surgery, which she had approximately 3 years ago.
Laryngeal cancer
Hypertension
Hypercholesterolemia
Pneumonia
Arthritis
Hypothyroidism
Atrial fibrillation
Acute renal failure
Chronic kidney disease, stage IV – on 07/30/2013 a renal biopsy was completed, which showed focal acute tubular necrosis and patchy tubular atrophy, moderate to severe interstitial fibrosis with patchy acute and chronic interstitial nephritis, normal cellular glomeruli with no white microscopic evidence of a primary glomerulopathy. Baseline creatinine is 1.9.
Peptic ulcer disease
Skin cancer
Anemia
Osteoporosis
PAST SURGICAL HISTORY:
Laparoscopic gastric bypass – 3 years ago
Closure of mesenteric defect.
Radical neck resection on -3 months ago
FAMILY HISTORY:
Mother has diabetes diagnosed at age 55 and high blood pressure. She is deceased.
Father had heart disease diagnosed at age 60. He is deceased.
She had a sister with diabetes, thyroid disease, CKD, on dialysis, with unknown etiology.
SOCIAL HISTORY: She denies any smoking or alcohol use. She denies any drug use.
MEDICATIONS:
Calcitriol 0.5 mcg PO every other day
Vitamin B12 2500 mcg sublingual every Monday and Thursday
Docusate sodium 100 mg PO BID
Fentanyl patch 100 mcg every 72 hours
Gabapentin 800 mg PO BID
Levothyroxine 50 mcg daily
Multivitamin 1 PO Daily
Oxybutynin 5 mg PO BID
Hydrocodone 5/325 1-2 tablets every 6 hours PRN pain
ALLERGIES: SHE IS ALLERGIC TO CIPRO, WHICH CAUSES URTICARIA AND HIVES, CONTRAST DYE, HONEY AND BEE VENOM, ADHESIVE, AND SULFAS, WHICH CAUSE HIVES.
PHYSICAL EXAMINATION:
Vital signs: 38.6, 120, 22, 138/38, 64% on room air. O2 sat of 91 on 4 liters nasal cannula.
Constitutional: She is somnolent. Oriented to person and place. Appears ill and mildly dyspneic.
Head: Normocephalic and atraumatic. Nose: Midline, right and left maxillary and frontal sinuses are nontender bilaterally.
Oropharynx: Clear and moist. No uvula swelling or exudate noted.
Eyes: Conjunctivae, EOM and lids are normal. PERL. Right and left eyes are without drainage or nystagmus. No scleral icterus.
Neck: Normal range of motion and phonation. Neck is supple. No JVD. No tracheal deviation present. No thyromegaly or thyroid nodules. No cervical lymphadenopathy noted bilaterally.
Cardiovascular: rapid rate, S1 and S2 without murmur or gallop. Brachial, radial, dorsalis pedis, and posterior tibial are 2+/4+ bilaterally.
Chest: Respirations are regular and even with mild dyspnea.
Lungs are coarse and with some rales posterior bases.
Abdomen: Soft. Bowel sounds are active, nontender, no masses noted. No hepatosplenomegaly noted. No peritoneal signs.
Musculoskeletal: Full range of motion of the bilateral shoulders, wrists, elbows.
Neurologic: Somnolent. Cranial nerves II-XII are intact.
Skin: Warm and dry.
Psychiatric: Mood and affect are normal. Calm and cooperative. Behavior, judgment is intact.
LABORATORIES AND DIAGNOSTICS:
