Name: Allan Z.
MRN: 123456
DOB: 02/19/1954
Age: 58
CC: In-patient consult for hemoptysis. Began coughing up “clots” of blood last night in tissues and
informed nursing staff.
Subjective:
Patient is a quiet 58 y/o Caucasian male with a complex history of depression. He presented to the ED
on 7/1/12 after taking 10 Vicodin 10/500mg tablets in a suicide attempt. This was his second suicide
attempt in two years and he has also admitted to abusing alcohol prior to his ingestion of Vicodin. He
was admitted to the psychiatric unit of the hospital after he was released from the ED. He currently is
being treated by the psychiatric service and is also receiving Electroconvulsive Therapy (ECT) as an inpatient. Yesterday he developed a cough and produced bloody sputum. He describes the sputum as
more blood than mucus and showed his nurse, who sought the pulmonary service for a consultation.
Patient was able to show a tissue with thebright red or brown??? bloody sputum which was found to be
consistent with this description. He states that he produced bloody sputum “several” times through the
night and early morning, but has not experience any additional coughing or sputum since this morning.
Patient denies experiencing any pain associated with the cough, but does say his back and neck pain is a
5/10with 10 being…. This is the 1st mention of back and neck pain tell me moreHe denies shortness of
breath, chest pain, nose bleeds, trauma and wheezing. He states that nothing made the coughing better
or worse and that it “went away on its own.” Patient denies that the blood came from vomiting and
denies any nausea. He denies ever having experienced a similar episode and cannot previously recall
coughing up any blood. Patient also denies previous exposure to tuberculosis or travel. He had
previously used Vicodin for his back and neck pain, but since his suicide attempt he is now prescribed
Tylenol, 600mg TID. Patient states he does feel fatigued and depressed. He also admits to feeling
nervous and anxious at times. Patient denies fever, chills, weight gain or weight loss, night sweats, and
headaches. He also denies dysphagia, heartburn, diarrhea, hematochezia, or melena.
Family Hx: Patient is married and lives with his wife in Lancaster; He has two adult step-sons who live in
the area; Past family history is significant for alcoholism and diabetes on his mother’s side and
cardiovascular disease on his father’s side.
Social Hx: Works at the Presbyterian church in Lancaster where his wife also is employed; Admits to
previous history of smoking for “several” years, but says he quit many years ago and was unable to
remember exactly when or how much he smoked; Has a history of alcohol abuse and was a recovering
alcoholic for three years until he relapsed on 7/1/12; Denies any use of illicit drugs.
Allergies: Metformin, Oxycodone reaction???
Immunizations: Current
Medications: Glipizide 10 mg PO daily; Lisinopril 20 mg PO daily; Ritalin 10 mg PO BID; Simvastatin 5 mg
Q PM; Tylenol 600 mg TID; Fluoxetine 40 mg PO AM; Cymbalta 60 mg PO Q daily; Hydorchlorothiazide
25 mg PO Q daily
PMH: Diabetes, Hypertension, Major Depressive Disorder, Sleep Apnea, MI, Prostate Cancerno mention
of this above or in the assessment
chronic back and neck pain or was it new???
PSH: Appendectomy (approximately 1969), Cervical arthrodesis (2001)is this the cause of his pain???
Objective: Vitals: Temperature: 98.8F (oral) P: 87 R: 16 BP: 154/93 SpO2: 95% Height: 71 inches
Weight: 245lbs. BMI: 34.2
General Appearance: Flat affect, alert and oriented X3
Nose: No lesions, obstruction, redness or exudate found upon exam; no tenderness upon palpitation of
frontal, maxillary, or ethmoid sinuses
Throat: Erythematous gingiva noted, with multiple dental caries found; No gross blood, lesions, or ulcers
found; tongue midline and symmetrical with no masses/ulcers noted; pharynx erythematous, no
lesions/exudate; uvula symmetrical, no redness notedcontradicting
Lymph nodes and thyroid??????
Chest: No scarring, asymmetry, striae, or ecchymosis of chest; No use of accessory muscles noted; Chest
wall expansion is equal bilaterally without intercostal retractions; A:P ratio is 2:1; No tenderness or
fremitus on palpation; Lung fields clear to percussion bilaterally; Upon auscultation dry breath sounds
present and equal bilaterally in apices and bases, with no wheezing/rales/rhonchi/stridor appreciated
Heart: Regular rate and rhythm; no murmurs or rubs; S1 and S2 appreciated
Skin: No contusions, rashes, bleeding, or lesions noted; skin is warm and dry
Peripheral Vascular: No edema of the upper or lower extremities noted; Radial and Dorsalis Pedis pulses
palpated, present and equal bilaterally, +2/4
ABD?????
Labs/Tests: CBC with differential: ordered
Bronchoscopy: scheduled
Chest X-ray: No infiltrates, atelectasis, or pneumothorax of the lungs. No cardiomegaly
noted
Assessment: 1) Major Depressive Disorder
2) Hemoptysis
3) Hypertension
4) Diabetes Mellitus
5) Sleep Apnea
Differential Diagnosis: Infection of respiratory tract, Pneumonia, Neoplasm, Foreign body,
Pulmonary embolism, Pulmonary hypertension, Tuberculosis, Idiopathic hemoptysis,
Goodpasture’s syndrome, Wegener’s granulomatosis
Plan:
1) Major Depressive Disorder: Hospital psychiatric service is currently working with Mr. Z in the inpatient setting where he is receiving counseling, adjustment of his antidepressant medications
and is also receiving ECT treatments several times a week. Patient, family and psychiatry are
currently investigating the option of an intensive outpatient program for Mr. Z upon his
discharge.
2) Hemoptysis: Mr. Z is scheduled for a bronchoscopy to evaluate the bronchial tree tomorrow
with Dr. Dolina. Patient initially was also scheduled to receive an ECT treatment early tomorrow
morning, but because both procedures would require anesthesia, his ECT was rescheduled for
next week. Patient expressed some disappointment that his ECT would be delayed, but upon
further discussion agreed that the bronchoscopy should be performed as soon as possible.
Written consent for the bronchoscopy was obtained and he was advised of the risks of the
procedure including collapse of the lung, bleeding, damage to the bronchial tree and infection.
He was also advised that he needed to be NPO after midnight. Patient is also scheduled for a
CBC with differential to be collected tomorrow morning.
3) Hypertension: Continue patient on current medicine regimen and continue to monitor vitals.
Vital signs are currently ordered for every 6 hours.
4) Diabetes Mellitus: Continue glipizide 10 mg PO daily and continue to monitor blood glucose
levels. Patient is on a “consistent carb” diet in the hospital.
5) Sleep Apnea: Continue use of CPAP machine as directed. Machine is in patient’s room and he
states he has been using it every night. Patient follows up annually with Dr. Jean in the
pulmonology group for sleep apnea.
In addition, Mr. Z is scheduled to follow up with his PCP following his discharge. Patient states that he
does visit his PCP “at least” annually where he monitors his prostate cancer and obtains annual
colonoscopies as well as “blood work.” Mr. Z denies any additional questions and agreed to comply with
the pre-procedure protocol for the bronchoscopy.
25/30
Vanessa G Wittstruck, PA-S
7/12/12
11:22