SUBJECTIVE: The patient presents for evaluation of lung cancer and chronic obstructive pulmonary disease status post recent hospitalization.
He presented with a change in his cough, hemoptysis, and back pain. History, as performed by Dr. XXXX, states that because of the patient’s dementia getting an exact complaint was a bit difficult. The initial examination, however, showed that his vital signs were quite acceptable with a temperature of 97.8 and oxygen saturation 97% on room air. He also appeared in no acute distress.
He underwent chest radiographs and CT scans, and an increase in the posterior cavitary mass was noted with an air fluid level. He was treated with ciprofloxacin and Augmentin and recommended to continue this for three weeks.
Since he has been discharged, his symptoms have improved. He continues to have a cough, which is productive of dark-colored sputum but no hemoptysis. His chest pain has resolved. He has never had a fever. His appetite is improved. He has gained 2 pounds. The home physical therapist has discharged him, and he is now a bit more ambulatory.
The patient has been unable to crush the pills and so his current medications include Advair Diskus 500/50 one twice daily, diltiazem CR 180 daily, ProAir HFA p.r.n. fairly infrequently, and Spiriva HandiHaler 1 capsule daily.
OBJECTIVE: On examination, blood pressure is 152/80, heart rate 60, weight 101 pounds, oxygen saturation 99% on room air. Pain score is 0. The patient is very pleasant, in no acute distress. He does not answer much in the way of questions. He does appear in no acute distress; however, he is somewhat cachectic, and on examination of the chest, he has diffuse scattered upper airway rhonchi throughout all lung fields. Cardiac exam is regular, somewhat obscured. Extremities are without edema.
Chest x-rays and CT scans are reviewed, and there is a change in the right hemithorax now with progressive volume loss. The cavitary abnormality posteriorly is now a bit more thick-walled and fluid-filled than it was even in January of this year. There is also a large hiatal hernia present.
ASSESSMENT AND PLAN: The patient is an (XX)-year-old gentleman with history of lung cancer status post radiofrequency ablation and external beam radiotherapy complicated by pneumothorax. He has also asthma and chronic obstructive pulmonary disease and has had previous pulmonary emboli in the past.
In addition to the above, he has progressive and now fairly severe dementia.
He has fortunately recovered from his recent illness, which may have been related to an acute pulmonary abscess. There does appear, however, to be a change in the right hemithorax and we wonder whether the cancer has progressed.
We spent little time talking with the patient today about end-of-life issues including a DO NOT RESUSCITATE and comfort measures only. It does appear that during a recent admission, the patient was “full code,” and we think especially given the probable recurrent cancer and severe advanced dementia, this is not in his best interest.
We described that should he require intubation and mechanical ventilation, it would be unlikely that he would be liberated and this would be a difficult, likely a fairly frightening thing for the patient to undergo. The family tends to agree with us on the surface of this and in fact does appear they would like to pursue a comfort measures only approach and would like to think about this further. We will continue to be available on an as-needed basis.
