879492218 YC
53470378
3210349
6/26/2004 12:00:00 AM
PNEUMONIA
Signed
DIS
Admission Date :
06/26/2004
Report Status :
Signed
Discharge Date :
07/08/2004
ATTENDING :
MALTA FYFEZEISLEITZ MD
CHIEF COMPLAINT :
Shortness of breath .
HISTORY OF PRESENT ILLNESS :
The patient is a 38-year-old gentleman , Spanish-speaking , from the Taheimpromong , with no significant past medical history , who presents with shortness of breath x 2 months as well as a dry cough x 1 month .
The patient was in his usual state of health until two months prior to admission when he began to notice shortness of breath on climbing flights of stairs .
He stated that this became worse over the last month until he was noted to be short of breath at rest .
He also states that he has had a dry and nonproductive cough for one month .
He denied any fevers , chills , or night sweats .
No nausea , vomiting , or diarrhea .
He did note some weight loss over the past several months , though the amount was unknown .
He denied any contact with TB positive patients .
He describes a negative PPD one year prior to admission when he was in prison for one week .
He did travel to the Taheimpromong , last in 01/2004 for three weeks .
He did note multiple female sexual partners , although described using condoms except with his wife .
He denies any IV drug use , did describe cocaine use last two months ago .
He did drink alcohol three drinks per day , no withdrawal symptoms .
In emergency room , he was noted to be afebrile with stable vital signs , was treated with IV fluids , azithromycin , and cefuroxime .
PAST MEDICAL HISTORY :
None .
MEDICATIONS :
None .
ALLERGIES :
No known drug allergies .
SOCIAL HISTORY :
The patient lives currently with a friend , he is from the Taheimpromong and has lived here for 13 years , he does note multiple sexual partners , although he notes using condoms with everyone except his wife , he reportedly had a negative PPD during his prison stay one year ago for one week .
He traveled to the Taheimpromong last in 01/2004 for one month .
He does drink alcohol three drinks per day , denies any current tobacco use .
FAMILY HISTORY :
Sister with bone cancer .
PHYSICAL EXAMINATION UPON ADMISSION :
Temperature 97.4 , heart rate 100 , blood pressure 142/89 , and O2 saturation 94% on room air .
General exam revealed a well-developed , well-nourished gentleman in no acute distress .
HEENT exam revealed sclerae to be injected .
Pupils equal , round , and reactive to light .
No lymphadenopathy was noted in the neck , there was a question of right axillary lymphadenopathy .
Chest exam reveals coarse rhonchi with some bibasilar crackles .
Abdominal exam revealed soft , nontender , and nondistended abdomen .
Heart exam was regular rate and rhythm , tachycardic , with a flat jugular venous pressure .
His extremities were without cyanosis , clubbing , or edema .
His skin was clear , without rashes .
There is no hepatosplenomegaly noted on abdominal exam .
Neuro exam was alert and oriented x 3 .
LABORATORY DATA UPON ADMISSION :
Sodium 139 , potassium 3.5 , chloride 103 , bicarbonate 25 , BUN 9 , creatinine 0.9 , and glucose 83 .
White blood cell count 11.2 , hematocrit 43.2 , and platelets 447,000 .
EKG upon admission :
Sinus tachycardia at 100 .
Chest x-ray upon admission :
Diffuse interstitial process / consolidation .
HOSPITAL COURSE BY SYSTEM :
1. Pulmonary / Infectious Disease :
The patient 's differential diagnosis included initially a question of an atypical pneumonia or PCP .
His PPD has been negative one year prior to admission , PPD was rechecked during this admission and was negative .
He was ruled out for tuberculosis with an induced sputum x 3 , which showed no AFB .
Chest CT showed bibasilar diffuse infiltrates , PCP was negative .
Thus initially he had been started on prednisone and Bactrim , this was discontinued .
He was continued on azithromycin and cefuroxime until bronchoscopy results were known , negative .
Thus they were discontinued .
He initially had refused HIV testing , however , was finally consented , HIV was noted to be negative .
Pulmonary consult was invited , initially the patient refused bronchoscopy , however , did agree to it during his hospital stay .
The results were negative for Micro , most likely diagnosis as per review of pathology is organizing pneumonia with possible diagnosis of BOOP and chronic inhalational injury was a possibility .
The patient required supplemental oxygen to keep his oxygen saturation greater than 93% .
Ambulatory saturation was 82% on room air .
He was treated with supportive medical therapy for his cough .
He was to follow up with pulmonary as an outpatient .
2. Cardiovascular :
Echocardiogram was checked to rule out CHF , showed LVH and trace TR , ejection fraction of 60% without any pulmonary hypertension .
3. Heme
/ID :
Hepatitis serologies were negative .
4. FEN :
The patient was kept on a house diet .
His electrolytes were repeated p.r.n.
5. Prophylaxis :
Lovenox .
6. Code status :
Full .
7. Disposition :
The patient was discharged to home in satisfactory condition with home oxygen .
Multiple conversations were had with the patient as well as an interpreter stating the importance of not smoking and keeping flames away from his oxygen tank .
He was sent home with LDAMC services to help with his medications as well as oxygen education .
He was told to call a doctor or come to the emergency room should he have any further troubles , breathing , chest pain , or fevers .
He was to follow up with Dr. Malta at Firmert Hospital on 07/23/04 at 3:00 p.m. , as well as Dr. Shawn Leick at the Stonho Health Care pulmonary division as directed .
DISCHARGE MEDICATIONS :
1. Prednisone 60 mg p.o. q.a.m.
2. Bactrim double strength one tablet p.o. q.d. for PCP prophylaxis during his steroid course .
eScription document :
0-3054851 WEBCtug Tel
CC :
Mata Fyfezeisleitz MD Verla
Dictated By :
KOTEHARBE , THRYNE
Attending :
FYFEZEISLEITZ , MATA Dictation ID 5149122
D :
11/06/04
T :
11/07/04