Consult - History and Phy.
Sample Name: Sleepiness - Consult
Description: Severe back pain and sleepiness. The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes with a low blood pressure.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Severe back pain and sleepiness.
The patient is not a good historian and history was obtained from the patient's husband at bedside.
HISTORY OF PRESENT ILLNESS: The patient is a 76-year-old obese Caucasian female with past medical conditions that includes hypertension, history of urinary incontinence, dementia, and chronic back pain, basically brought by the husband to the emergency room because of having excruciating back pain. As per the husband, the patient has this back pain for about almost 1 year and seeing Dr. X in Neurosurgery and had an epidural injection x2, and then the patient's pain somewhat got better between, but last time the patient went to see Dr. X, the patient given injection and the patient passed out, so the doctor stopped giving any other epidural injection. The patient has severe pain and all in all, the patient cries at home. As per the husband, the patient woke up in the morning with severe pain, unable to eat, drink today, and crying in the morning, so brought her to the emergency room for further evaluation. The patient denied any history of fever, cough, chest pain, diarrhea, dysuria or polyuria. While I was examining the patient, the patient explained about possible diagnosis and treatment plan and possible nursing home discharge for pain control. The patient passed out for about 3 to 4 minutes, unable to respond to even painful stimuli. The patient's heart rate went down to 50s and blood pressure was 92 systolic, so the patient was later on given IV fluid and blood pressure checked. The patient woke up after 5 to 6 minutes, so the patient was later on evaluated for admission because of near syncopal episode.
PAST MEDICAL CONDITIONS: Include hypertension, dementia, urinary incontinence, chronic back pain, and degenerative joint disease of the spine. No history of diabetes, stroke or coronary artery disease.
SURGICAL HISTORY: Include left total hip replacement many years ago, history of hysterectomy, and appendectomy in the young age.
CURRENT MEDICATIONS: According to the list shows the patient takes hydrocodone 10/325 mg every 6 hours, Flexeril 10 mg p.o. at bedtime, and Xanax 0.25 mg p.o. 4 times a day. The patient also takes Neurontin 200 mg 3 times a day, propranolol 10 mg twice a day, oxybutynin 5 mg p.o. twice a day, Namenda 10 mg p.o. daily, and Aricept 10 mg p.o. daily.
SOCIAL HISTORY: She lives with her husband, usually walks with a walker and wheelchair-bound, does not walk much as per the husband knows. No history of alcohol abuse or smoking.
GENERAL: Currently lying in the bed without apparent distress, very lethargic.
VITAL SIGNS: Pulse rate of 55, blood pressure is 92/52, after IV fluid came up to 105/58.
CHEST: Shows bilateral air entry present, clear to auscultate.
ABDOMEN: Soft, nondistended, and nontender.
EXTREMITIES: Shows the patient's straight leg raising to be only up to 30% causing the patient severe back pain.
IMAGING: The patient's x-ray of the lumbosacral spine done shows there is a L1 compression fracture with some osteophyte formation in the lumbar spine suggestive of degenerative joint disease.
LABORATORY DATA: The patient's lab test is not done currently, but previous lab test done in 3/2009 seems to be in acceptable range.
IMPRESSION: The patient, because of near syncopal episode and polypharmacy, almost passed out for about 3 to 4 minutes in front of me with a low blood pressure.
1. Vasovagal syncope versus polypharmacy because of 3 to 4 medications and muscle relaxants.
3. Hypertension, now hypotension.
4. Incontinence of the bladder.
5. Dementia, most likely Alzheimer type.
PLAN AND SUGGESTION: Initial plan was to send the patient to the nursing home, but because of the patient's low blood pressure and heart rate low, we will admit the patient to DOU for 23-hour observation, start the patient on IV fluid, normal saline, 20 mEq KCl, and Protonix 40 mg, and we will also continue the patient's Namenda and Aricept. I will hold the patient's hydrocodone. I will hold the Flexeril and I will also hold gabapentin at this moment. We will give the patient's pain control with Percocet and very minimal morphine sulfate as needed. Also give the patient calcium with vitamin D and physical therapy. We will also order a blood test and further management will be based on the patient's all test results. I also explained to the husband that tomorrow if the patient is better and more alert and awake, then we will send her to the nursing care versus home, it depends on the pain control.
Keywords: consult - history and phy., vasovagal syncope, polypharmacy, osteoporosis, hypertension, hypotension, alzheimer type, dementia, degenerative joint disease, syncopal episode, iv fluid, blood pressure, sleepiness,