Daniel DeMarco                                               SOAP Note #4                           Internal Medicine

S

VF is a 67yo Right-Handed female with PMH left hemiparesis s/p hemorrhagic stroke, chronic respiratory failure s/p trach on vent, s/p peg tub, COPD, HTN initially brought from Nursing Home to ED for left facial numbness. Now with Left Upper Lobe Pneumonia 2’ to P. aeruginosa. This AM she is in good spirits. She is speaking. She is tolerating her trach collar. No complaints at this time.

O

VS

T 37.1C, HR 73bpm, BP 130/61, RR 25 breaths/min, SpO2 100% RA

PE

Gen: Lying comfortably in bed with tracheostomy tube. Speaking and AOx3. No apparent distress.

CV: Regular rate and rhythm. S1 and S2. No murmurs, gallops, rubs.

Pulm: Chest expansion symmetrical. No accessory muscle use. Clear to auscultation bilaterally. No wheezing, rhonchi, rales, dullness.

Abd: Soft, non-distended, non-tender. Normoactive BS. No guarding, rebound.

Extremities: No deformity or joint abnormality. Minimal edema. Left foot drop present. Peripheral pulses intact.

Neuro:

Cerebrum: AOx3. Conversational.

CN: Pupils 2-3mm reactive, EOMs full, able to puff cheeks, left lower facial droop, symmetric rise of uvula, can shrug both shoulders, tongue is midline on protrusion.

Motor: Right upper extremity 5/5, Right lower extremity 5/5, Left upper extremity 0/5, Left lower extremity 0/5.

Cerebellum: Right Finger-to-nose intact. Unable to perform Left Finger-to-nose.

Sensory: Grossly intact throughout.

Reflexes: Right Wrist 2+, Right Patella 2+, Left Foot with Clonus 4+, Left Babinski absent, Right Babinski present

Labs

3/25/2019

9.9

8.45> 31.7 <303

 

136 | 94 | 13 < 156

4.0 | 32 | 0.5

Mg2+: 2.1

 

A/P

VF is a 67yo Right-Handed female with PMH left hemiparesis s/p hemorrhagic stroke, chronic respiratory failure s/p trach on vent, s/p peg tub, COPD, HTN with Left Upper Lobe Pneumonia 2’ to P. aeruginosa.

Respiratory/Infectious

#Acute on Chronic Respiratory Failure with Hypercapnia and Hypoxia – Improving

#Left Upper Lobe Cavitary Pneumonia 2’ to P. aeruginosa – Improving

• Blood Cultures Negative
• Respiratory Culture from 3/23 showed Pseudomonas aeruginosa sensitive to Piperacillin/Tazobactam
• Piperacillin/Tazobactam 3.375g tid (Day 6/14); Last day of antibiotics planned for 4/4/2019
• Tolerating tracheostomy collar and Passey Muir valve
• Plan for PICC Placement
• Plan for transfer to Ventilator Facility later this week

Cardiovascular

#Essential Hypertension – Stable

• Amlodipine 10mg qd
• Losartan 100mg qd
• Metoprolol 75mg tid

Hematology

#Normocytic Anemia – Stable

• Last hemoglobin/hematocrit of 9.9/31.7
• to monitor

Metabolic

#Hypokalemia – Stable

• Last K+ 4.0, Last Mg2+ 2.1
• Cont. to monitor

Neurologic

#R Thalamocapsular Hemorrhagic Stroke – Chronic

#Left Facial Numbness – Resolved

• CT brain 3/19 showed resolution of R thalamocapsular hemorrhage
• Levetiracetam 500mg bid

#Anxiety – Stable

• Alprazolam 0.25mg tid
• Paroxetine 20mg qd

Prophylaxis

#GI Prophylaxis – Stable

#Tracheostomy Prophylaxis – Stable

• Docusate 50mg/5mL liquid 100mg tid
• Famotidine tablet 20mg qd
• Chlorhexidine 0.12% solution 15mL bid, swish and spit

 

DVT Prophylaxis: Heparin SubQ

Nutrition: Tube feeding via PEG

Dispo: Plan for Transfer to Ventilator Facility later this week

 

Case discussed with Dr. Siasoco MD who agrees with A/P.

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student