ADMITTING DIAGNOSES:
1. Respiratory failure, on continuous aerosolized trach collar during the day and ventilator at night.
2. Pickwickian syndrome.
3. Morbid obesity.
4. Renal insufficiency.
5. Diabetes mellitus type 2.
6. Cor pulmonale.
7. Pulmonary hypertension.
8. Hypertension.
9. Gout.
SOURCE OF INFORMATION: The patient as well as the discharge summary.
HISTORY OF PRESENT ILLNESS: This is an extremely pleasant (XX)-year-old morbidly obese male. He was diagnosed with pulmonary hypertension 12 years ago. He had a recent decompensation of his heart failure secondary to pulmonary hypertension and was admitted to an outside hospital. He was treated in the intensive care unit. He did develop worsening respiratory failure, and a tracheostomy was eventually done.
He was transferred here for further management of primary diagnosis, respiratory failure, with tracheostomy, on continuous aerosolized trach collar during the day as well as ventilator at night and secondary diagnosis of pulmonary hypertension with cor pulmonale. The patient, having been previously independent at home, would like to return home once again.
He will receive aggressive physical and occupational therapies as well as progressing to cardiopulmonary rehabilitation as well prior to his discharge home.
FAMILY HISTORY: The patient states the family history is noncontributory. No history of cancer in the family.
PSYCHOSOCIAL HISTORY: The patient, as mentioned, was previously living independently at home. He has no steps to enter or within the home. He denies any previous alcohol or tobacco use. The patient did wear home O2 at 5 liters per nasal cannula but was able to perform all activities of daily living as well as cooking and cleaning for himself and transportation, transporting himself to the grocery store as well as doctor’s appointments with his oxygen.
REVIEW OF SYSTEMS: The patient does not have impaired hearing. He claims not to have any swallowing difficulties. He is unable to speak currently secondary to tracheostomy, on continuous aerosolized trach collar. There is no goiter. He does have ankle swelling secondary to his pulmonary disease as well as shortness of breath with exertion. He denies any chest pains. He does not have palpitations. The patient does take a p.o. diet. There is no tube feeding. He denies any heartburn, nausea, vomiting, diarrhea or constipation. There have not been any bloody or tarry stools. He does have a Foley catheter in place. There are no rashes other than venous stasis changes on his lower extremities bilaterally. He denies any headaches, blackouts, dizzy spells or seizures.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 97.9 degrees, pulse 88, respirations 20 and blood pressure 172/80. GENERAL: This is a very pleasant (XX)-year-old morbidly obese male. He is talkative and appropriate. He is in no apparent distress, on continuous aerosolized trach collar at 60%. HEENT: Extraocular movements are intact. Pupils are equal, round and reactive to light. No scleral icterus is present. He does have a slight white coating on his tongue, but mucous membranes are moist. There is no cervical lymphadenopathy. Trach site is clean and dry. CARDIOVASCULAR: Regular, S1 plus S2. Heart sounds are normal, dynamic. PULMONARY: Breath sounds are equal bilaterally. Markedly decreased in the lower half of bilateral lungs. There are no wheezes, rales or rhonchi able to be auscultated. GI: Abdomen is markedly obese, soft, nontender and nondistended. Positive bowel sounds heard throughout all 4 quadrants. Unable to palpate any masses or hepatosplenomegaly. EXTREMITIES: Warm and dry. There are 1-2+ bilateral lower extremities with venous stasis skin changes of the lower extremities bilaterally as well. NEUROLOGIC: The patient is alert and oriented x3. He has no focal deficits noted.
ADMISSION MEDICATIONS:
1. Lasix 80 mg p.o. q.d.
2. Celexa 40 mg p.o. q.d.
3. Coumadin 2 mg p.o. q.h.s.
4. Lanoxin 0.25 mg p.o. q.d.
5. Norvasc 10 mg p.o. q.d.
6. Nystatin powder to groin b.i.d. p.r.n. yeast.
7. Theophylline 300 mg p.o. q.12h.
8. Zyloprim 300 mg p.o. q.d.
9. Ambien 10 mg p.o. q.h.s. p.r.n. sleep.
10. Ativan 2 mg p.o. q.i.d.
11. Vicodin 5/500 mg one p.o. q.4h. p.r.n. moderate to severe pain.
12. Albuterol 0.5 mL and unit dose Atrovent hand-held nebulizer q.4h. plus q.2h. p.r.n.
ASSESSMENT AND PLAN:
1. Respiratory failure. On continuous aerosolized trach collar during the day as well as ventilator at night. We will consult Pulmonology for assistance with trach collar and ventilator management and weaning. Continue aggressive hand-held nebulizer treatments and pulmonary toilet. Ultimate goal is certainly to wean the patient from his nighttime ventilator usage, maybe slightly more difficult to take the patient off the aerosolized trach collar long term. I suspect this is a patient whose lung disease is fairly advanced. It may require chronic tracheostomy, especially with the likelihood of needing increased ventilation at night secondary to his pickwickian syndrome.
2. Pulmonary hypertension. We will continue anticoagulation with Coumadin, checking PT and INR values on Mondays and Thursdays.
3. Cor pulmonale. The patient is on Lasix. We will watch fluid status carefully.
4. Renal insufficiency. Check basic metabolic panel in the morning. Watch creatinine closely, on regimen of Lasix. The patient is currently not on any potassium supplementation. We will possibly need to start this if he has major losses of potassium secondary to diuretics.
5. Hypertension. Currently, the patient is slightly hypertensive on admission. I suspect that this is secondary to just having been transported and moved around. We will follow up in the morning to see if blood pressure has normalized. We will continue Norvasc and add further agents as needed.
6. Depression. Continue Celexa.
7. Anxiety. We will continue Ativan.
8. Gout. Continue Zyloprim, currently asymptomatic.
