Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 53
The patient is a 61-year-old lady who was found down at home and was admitted for respiratory failure, septic shock, acute renal failure as well as metabolic acidosis.
(Medical Transcription Sample Report)
The patient is a 61-year-old lady who was found down at home and was admitted for respiratory failure, septic shock, acute renal failure as well as metabolic acidosis.HISTORY OF PRESENT ILLNESS:
Goes back to yesterday, the patient went out for dinner with her boyfriend. The patient after coming home all the family members had some episodes of diarrhea; it is unclear how many times the patient had diarrhea last night. She was found down on the floor this morning, soiled her bowel movements. Paramedics were called and the patient was brought to the emergency room. The patient was in the emergency room noted to be in respiratory failure, was intubated. The patient was in septic shock with metabolic acidosis and no blood pressure and very rapid heart rate with acute renal failure. The patient was started on vasopressors. The patient was started on IV fluids as well as IV antibiotic. The CT of the abdomen showed ileus versus bowel distention without any actual bowel obstruction or perforation. A General Surgery consultation was called who did not think the patient was a surgical candidate and needed an acute surgical procedure. The patient underwent an ultrasound of the abdomen, which did not show any evidence of cholecystitis or cholelithiasis. The patient was also noted to have acute rhabdomyolysis on the workup in the emergency room.PAST MEDICAL HISTORY:
Significant for history of osteoporosis, hypertension, tobacco dependency, anxiety, neurosis, depression, peripheral arterial disease, peripheral neuropathy, and history of uterine cancer.PAST SURGICAL HISTORY:
Significant for hysterectomy, bilateral femoropopliteal bypass surgeries as well as left eye cataract surgery and appendicectomy.SOCIAL HISTORY:
She lives with her boyfriend. The patient has a history of heavy tobacco and alcohol abuse for many years.FAMILY HISTORY:
Not available at this current time.REVIEW OF SYSTEMS:
As mentioned above.PHYSICAL EXAMINATION:
GENERAL: She is intubated, obtunded, gangrenous ears with gangrenous fingertips.
VITAL SIGNS: Blood pressure is absent, heart rate of 138 per minute, and the patient is on the ventilator.
HEENT: Examination shows head is atraumatic, pupils are dilated and very, very sluggishly reacting to light. No oropharyngeal lesions noted.
NECK: Supple. No JVD, distention or carotid bruit. No lymphadenopathy.
LUNGS: Bilateral crackles and bruits.
ABDOMEN: Distended, unable to evaluate if this is tender. No hepatosplenomegaly. Bowel sounds are very hyperactive.
LOWER EXTREMITIES: Show no edema. Distal pulses are decreased.
OVERALL NEUROLOGICAL: Examination cannot be assessed.LABORATORY DATA:
The database was available at this point of time. WBC count is elevated at 19,000 with the left shift, hemoglobin of 17.7, and hematocrit of 55.8 consistent with severe dehydration. PT INR is prolonged at 1.7 and aPTT is prolonged at 60. Sodium was 143, BUN of 36, and creatinine of 2.5. The patient's blood gas shows pH of 7.05, pO2 of 99.6, and pCO2 of 99.6. Bicarb is 16.5.ASSESSMENT AND EVALUATION:
1. Septicemia with septic shock.
2. Metabolic acidosis.
3. Respiratory failure.
5. Acute renal failure.
The patient has no blood pressure at this point in time. The patient is on IV fluids. The patient is on vasopressors due to ventilator support, bronchodilators as well as IV antibiotics. Her overall prognosis is extremely poor. This was discussed with the patient's niece who is at bedside and will become indicated with her daughter when she arrives who is on the plane right now from Iowa. The patient will be maintained on these supports at this point in time, but prognosis is poor.
consult - history and phy., anuria, septicemia, acute renal failure, iv fluids, respiratory failure, septic shock, metabolic acidosis,
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