HISTORY
Patient is an 81-year-old male who presents to my office for
recheck of his iron, but he states during the early morning hour, he get
chills, shakes. His wife checked his
temperature about 5 and it was 99 plus and about 5:30, he started burning up,
and she checked his fever is 101.6, and he was sweating. He said he has had a little cough, but he had
not feel bad. He said he has been
feeling actually pretty good. He was
here for recheck of his anemia initially and also he got clearance to go on O2
to up in Washington DC via flight. At my
seen, he was sitting on a wheelchair. He
has his 2 liters oxygen on. He is
hypoxic. We increased it to 3. His O2 sat was 85%. His chest has congestion left base and middle
lobe much more than the right. He cannot
getting this up though, we increased his O2 to 4 liters. He was given breathing treatment. He sat actually dropped to 81 ______
treatment he was having hard time getting his breathing. He has got to breath deep and he got back up
to 84% to 85%.
PAST MEDICAL HISTORY
He has severe COPD, that is followed by myself and Dr.
Goetter. He has been in the Birmingham
for research program, but he was turned down.
He is depended on O2 continuously.
He also has a history of BPH, history of renal stones, and history of
hypertension.
CURRENT MEDICATIONS
His current medications are numerous, included:
1. O2.
2. He is on
DuoNeb 4 times a day per nebulizer.
3. He has
albuterol for rescue every 3.
4. He is on
prednisone 10 milligrams a day.
5. He is on
theophylline 400 milligrams a day.
6. Spiriva
18 micrograms a day.
7. Advair
Diskus 500/50 b.i.d.
8. He is on
Lasix 1 a day.
9. Aldactone
50 milligrams a day.
10. Avodart 1
a day.
11. Hytrin 5
milligrams a day.
12. Zocor 20
milligrams a day.
13. He is on
Restoril 30 milligrams at night.
14. He is on
Protonix 40 milligrams a day.
15. He takes
B12 monthly.
16. He takes
Mucinex twice daily.
17. He takes
magnesium citrate p.r.n.
18. MiraLax
twice a day.
19. He has
been recently started on iron sulfate after Dr. Ives did a workup and really
just found diverticulosis, but no significant pathology.
FAMILY HISTORY
Noncontributory at this time.
SOCIAL HISTORY
He is married. His
wife is 20 plus years younger and takes very good care of him. He is without cigarettes for the past 9
years, but prior that he has about 100 to 120 pack a year history of
smoking. He drinks occasionally bourbon.
OBJECTIVE
VITAL SIGNS:
Patient's blood pressure is 90/52.
His pulse 104. He looks into be
mild to moderate respiratory distress.
He states once he breath deep, he can do okay in a wheelchair, but if he
gets up a while he is severely short of breath.
HEENT EXAM: His oropharynx
is somewhat dry. Oxygen in place. TM has hearing aids in place, otherwise looks
okay.
CHEST: He has
bilateral breath sounds or congestion noted in left base and left mid
lung. Decreased breath sounds in the
right, which is more of his chronicity.
CARDIAC: He has
tachycardic rhythm at 104 to 108.
ABDOMEN: Soft. He has positive bowel sounds. He has 1+ edema in his lateral plateau.
He has lots of superficial bruising and ecchymosis on his
arms and legs.
ADMISSION DIAGNOSES
1. Chronic
obstructive pulmonary disease exacerbation.
2. Hypertension.
3. Chronic
renal failure.
4. Anemia.
5. Benign
prostatic hypertrophy.
6. Hyperlipidemia.
7. Advanced
age.
8. Probable
cor pulmonale.
PLAN
At this time, I am going to admit to the hospital, start him
empirically on IV Levaquin 750 daily. He
had a PA and lateral chest x-ray. Resume
his home meds except for his diuretics with his pressure being low,
"supplement O2." Nebulizer
treatments every 6 round the clock every 3 p.r.n., continue the Advair. We will check CBC, electrolytes, sputum and
blood cultures. He is DNR at his
request.
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