DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: This is a (XX)-year-old female with generalized body weakness and slurring of speech, to rule out myasthenia gravis versus chronic demyelinating inflammatory polyneuropathy. The patient was found to have decreased inspiratory effort and transferred to ICU for close monitoring. Pulmonary/critical care consultation was requested to help with management.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old female who has been having generalized body weakness for a couple of months now, who was noted to have slurred and whispering speech over the last 2 to 3 days. The patient initially presented to the hospital with nausea, vomiting, and was found to have guaiac positive stool.
The patient underwent endoscopy, which showed hiatal hernia, narrowing of the distal esophagus consistent with gastroesophageal reflux disease. The patient underwent dilatation of her distal esophagus, and she was also found to have severe gastritis. Otherwise, her past medical history is significant for seizure disorder and questionable history of chronic alcohol use.
The patient also underwent CAT scan of the chest yesterday, which we reviewed, and it showed left lower lobe infiltrate. The patient currently is on Zosyn for pneumonia. The patient underwent swallowing evaluation today, which showed one episode of aspiration. The patient is currently having a nasogastric feeding tube in place. The patient states that respiratory status has been the same since this morning. She denies any increasing dyspnea. She denies any chest pain. She has been having cough on and off. She denies high-grade fever, chills or rigor.
The patient was seen this morning by Dr. John Doe, her neurologist, and was found to have low negative inspiratory force (-20) with the assessment of generalized muscle weakness to rule out myasthenia gravis. The patient was transferred to the ICU for close respiratory monitoring and possible ventilatory support. We discussed the case with Dr. John Doe, and the plan is to keep the patient in the ICU while making arrangement to transfer her to the outside facility for further diagnosis and management.
PAST MEDICAL HISTORY: Peptic ulcer disease; history of diverticulosis; history of colon polyp; history of supraventricular tachycardia; history of neuromuscular disorder, type of which is not specified. The patient had history of seizure.
PAST SURGICAL HISTORY: Significant for her colonic polyp removal and recent EGD.
MEDICATIONS AT HOME: Verapamil, Nexium, and Lamictal.
ALLERGIES: None.
FAMILY HISTORY: Not contributory.
SOCIAL HISTORY: The patient drinks alcohol on a regular basis; otherwise, there is no history of smoking. She lives with her husband.
REVIEW OF SYSTEMS: Limited due to her whispering voice. Otherwise, she denies any headache or blurring of vision. She denies difficulty with swallowing at this point. Actually, the patient had swallowing evaluation at bedside, and recommendation was to continue mechanical soft thin liquid and to give her medications with puree and water.
PHYSICAL EXAMINATION:
GENERAL: The patient is not in acute distress. She looks chronically sick.
VITAL SIGNS: Blood pressure 106/60, pulse rate 78 per minute, respiratory rate ranging between 18 to 22 per minute, and oxygen saturation is 95% on 2 liters. The patient is afebrile.
HEENT: Head is atraumatic. Pupils are equal, round, and reactive bilaterally. Oropharyngeal exam is within normal limits.
NECK: Supple.
CHEST: Symmetrical chest expansion and she has scanty rales in the left lower lung field.
HEART: S1, S2 was heard.
ABDOMEN: Soft, nontender. No organomegaly palpated.
EXTREMITIES: Without cyanosis or edema.
NEUROLOGIC: The patient has both upper and lower extremity weakness; otherwise, she is alert.
LABORATORY DATA: CBC from today showed WBC count 10.6, hemoglobin 10.8, hematocrit 33.6, and platelet count 322,000. Electrolyte panel: Normal sodium, potassium 3.3, chloride and bicarbonate normal. Glucose 102. BUN 7 and creatinine 0.5. ABG showed pH 7.42, PCO2 37, PO2 88, and saturation 97%.
ASSESSMENT: The patient is a (XX)-year-old female with past medical history significant for neuromuscular disorder, the type of which is not clear at this point, history of peptic ulcer disease, and gastroesophageal reflux disease who was seen for pulmonary/critical care consultation. The patient presented with abdominal pain, nausea, vomiting, and was found to have severe gastritis. The patient also had history of chronic alcohol use. During this hospitalization, the patient was evaluated by Psychiatry for possible dementia, and the diagnosis was adjustment disorder and delirium. The patient has been having weakness of all extremities, and she developed dysphonia over the last 2 to 3 days. The patient was evaluated by the neurologist, and current working diagnosis is to rule out myasthenia gravis versus chronic inflammatory polyneuropathy. The patient was found to have decreased negative inspiratory force and decreased vital capacity and was transferred to ICU for close monitoring. The patient currently does not seem to be in any distress, and her ABG does not suggest any CO2 retention. She has good oxygenation too. Otherwise, the patient also has left lower lobe pneumonia. She had swallowing evaluation at the bedside, and it does not show any significant aspiration.
RECOMMENDATIONS:
1. We will monitor the patient’s respiratory status closely by monitoring her negative inspiratory force and the vital capacity on every 2 hour basis.
2. We will put the patient on noninvasive positive pressure ventilator on a p.r.n. basis and at night to make sure the patient does not have hypoventilation when she sleeps.
3. The patient to be transferred to outside facility for further care once the bed is available as per her neurologist.
4. We will continue Zosyn for possible pneumonia coverage.
5. The patient will continue other medications as outlined by the primary team. We will follow up the patient closely and make appropriate recommendations based on her clinical response.
