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History and Physical Medical Transcription Sample Report

DATE OF ADMISSION:  MM/DD/YYYY

REASON FOR ADMISSION:  Respiratory failure with severe bronchospasm requiring a higher level of care.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old male with a history of asthma who has never been intubated before. The patient is unable to provide history and history taking is thus limited. The patient, according to the daughter, had been short of breath for the past 3 to 4 days with audible wheezing. He had been using her nebulizer machine without significant relief. He had a dry cough as well. There is no known fever, chills or pain. There were no ill contacts at home. According to the daughter, the patient's chief complaint was tightness in the chest. The patient was admitted and required intubation later that day for severe bronchospasm and respiratory failure. He has required heavy sedation and is being transferred here for pulmonary consultation and further ventilator management.

PAST MEDICAL HISTORY:  According to the daughter, he has a history of asthma, hypertension. No history of diabetes mellitus or heart disease, according to the daughter.

SOCIAL HISTORY:  According to the patient's daughter, he had no known occupational exposures. He never smoked tobacco or drank a large amount of alcohol. He is widowed and lives with his daughter.

ALLERGIES:  No known drug allergies.

FAMILY HISTORY:  Positive for asthma. The patient's sisters had cancer of unknown type. There is no history of heart disease or diabetes mellitus in the family, according to the daughter.

MEDICATIONS ON TRANSFER:  Solu-Medrol 60 mg IV q. 6 h., albuterol nebulized frequently, Levaquin 500 mg IV q. 12 h., propofol drip for sedation which was switched to fentanyl and Versed during air ambulance transport, vecuronium 7 mg twice during his air transport to facilitate ventilation and Zantac 50 mg q. 12 h.

PHYSICAL EXAMINATION:
GENERAL APPEARANCE:  Intubated and currently not responsive. By report, he had received sedation.
VITAL SIGNS:  Temperature 35.2 degrees Celsius, blood pressure 104/68, heart rate 48, respiratory rate 14, oxygen saturation 100% on 100% FiO2, on the ventilator. Current ventilator settings:  PCV bilevel ventilation with airway pressures of 40/5 leading to a tidal volume of 1.1 liters and FiO2 of 100%.
HEENT:  Head is normocephalic and atraumatic. Pupils are 4 mm and poorly reactive to light bilaterally.
LUNGS:  Poor air movement. Tight expiratory wheezes throughout.
CARDIOVASCULAR:  Bradycardic, regular. Normal S1 and S2. No audible murmur, rub or gallop.
ABDOMEN:  Normoactive bowel sounds. Soft, mildly distended. No tenderness elicited as the patient has been sedated. There is a well-healed suprapubic midline scar.
EXTREMITIES:  No edema, clubbing or cyanosis.
NEUROLOGIC:  The patient appears to be sedated and paralyzed. He does not move any extremities.

LABORATORY DATA:  The lab data here is pending. At the outside hospital, the sodium was 138, potassium 3.8, chloride 104, CO2 of 26, BUN 33, creatinine 1.4. Glucose was 246. BNP was 36. CPK was 436. LDH was 484. Troponin 0.06. White blood cell count was 10.2, hemoglobin 11.8, hematocrit 36.2 and platelet count 204,000. The differential on the white blood cell count was 87% segs, 6% lymphocytes and 6% monocytes. Arterial blood gas done prior to transfer showed a pH of 7.38, PCO2 of 46, PO2 of 192, bicarbonate 28 and oxygen saturation 100% on 48% FiO2 via SIMV mode.

DIAGNOSTIC DATA:  Chest x-ray revealed hyperinflated lungs with tip of endotracheal tube near the aortic knob in the airway. There were no focal infiltrates. Electrocardiogram is pending.

IMPRESSION:  The patient is a (XX)-year-old male with a reported history of asthma, who appears to have status asthmaticus and respiratory failure. He has been transferred here. The patient has been difficult to ventilate at times due to severe bronchospasm. The patient is currently quite bronchospastic and had initially arrived with tidal volumes in the 300 range with bilevel PCV ventilation and airway pressures of 40/5. This subsequently improved dramatically following multiple serial albuterol and Atrovent treatments, and the patient currently has tidal volumes in the 1 liter range. Given the inability to obtain a history from the patient, the trigger for his asthma exacerbation is unclear, but may be related to an episode of bronchitis given the report of a nonproductive cough from the daughter.

PLAN:
1.  Status asthmaticus:  The patient will be treated with high-dose Solu-Medrol and frequent albuterol and Atrovent metered dose inhalers. The patient will be empirically placed on Avelox for possible bronchitis. There is no evidence of pneumonia on his chest x-ray.
2.  Respiratory failure:  This appears to be related to his asthma exacerbation. We will adjust his ventilator to prolong his expiratory time as much as possible. Currently, with his set I-time, his I:E ratio is 1:4. We will attempt to minimize auto PEEP and reduce his PCV pressures accordingly and lower his tidal volume to the 500 mL range. The patient had been sedated and paralyzed to facilitate air transport. We are holding any further paralysis at this time to neurologically assess the patient. We will attempt to sedate him with Diprivan to maintain compliance with the ventilator, but should he become agitated and difficult to ventilate, then he may require paralytic agents again.
3.  Possible small bowel obstruction:  The patient reportedly had a distended abdomen and the abdominal films at the outside hospital revealed distended loops of small bowel, which were suspicious for partial or early small bowel obstruction. CT scan was done immediately prior to transfer here and has not been reviewed yet. There does not appear to be marked distension of the small bowel and we will review this with radiology and obtain a surgical consult accordingly. In the meantime, we will place him on n.p.o. status with his orogastric tube to low intermittent wall suction. The patient's abdomen is currently soft and difficult to assess due to his recent paralysis, but he does not appear to require a surgical intervention at this time.
4.  Routine medical ICU care:  The patient will be placed on a proton pump inhibitor for stress ulcer prophylaxis and we will place him on subcutaneous heparin for DVT prophylaxis. The patient will have an arterial catheter inserted for frequent ABG analysis and monitoring of his blood pressure, which is currently borderline. Should the patient have worsening hypotension or need additional IV access, we will insert a central venous catheter temporarily in the femoral region until a PICC line can be inserted, given the high risk of pneumothorax and severe subsequent consequences of a potential pneumothorax. We will use Diprivan for sedation, but we will need to decrease the dose given the borderline blood pressure and his bradycardia.
5.  Code status:  I discussed this with the patient's daughter, who indicates that the patient would want full code and full care status for now.