DISCHARGE SUMMARY

CHIEF COMPLAINT: Shortness of breath.

HISTORY OF PRESENT ILLNESS: This 52-year-old male was admitted as a direct admission from theclinic for worsening shortness of breath, hypoxia, tachypnea, fever, and severe anemia where he wasdiagnosed prior with probable pneumonia and was treated with Rocephin shots.

HOSPITAL COURSE: The patient was admitted to the hospital. He continued to have oxygen requirementup to 6 liters to keep his saturations at 90 or above. The patient was also noted to have a right eyeinflammation/infection going on. The patient was admitted. Throughout his stay, the first 2 days had verylittle improvement. He did receive Levaquin IV as well as breathing treatments as well as oxygen. Due to theseverity of the eye, ophthalmology was consulted who felt it was an inflammatory process and placed him onTobraDex, which he responded well to. We then consulted with internal medicine/pulmonary due to thenonresponse to therapy. A CT scan of the chest at that time revealed that there was no pneumonia. There wasa severe tracheitis/bronchiolitis. The patient was then placed on Decadron nebulizer as well as some Solu-Medrol and also added Zithromax to him. The patient responded well to this therapy and began to havemarked improvement rapidly of his symptoms with both copious amounts of sputum production as well asdecreased respiratory effort needed as well as increased PO2. The patient was also noted to be severelyanemic with a hemoglobin of 8 while he was in the hospital. He was transfused 2 units of whole blood, whichbrought his hemoglobin up to 10.2, and the patient's oxygen saturation levels did increase at that time also. Atthe time of discharge the patient is not requiring any oxygen. His room air oxygen saturations were 92%. Heis afebrile. He does have mild wheezes and is continued on his p.o. steroids.

DISCHARGE PHYSICAL EXAMINATION: General: A well-appearing male. Vital signs: Stable. Lungs:Mild scattered wheezes, however, markedly improved from prior and also good air movement noted.Cardiovascular: Regular rate and rhythm, no murmurs. Abdomen: Soft, nontender to palpation, nohepatosplenomegaly is noted. Skin: The patient is not cyanotic at this time.

DIAGNOSTIC STUDIES: Last CBC performed was on the ___ [DATE]. His white count was 6.8. Hishemoglobin was 10.1, hematocrit 31.4. His platelets are 674.

ASSESSMENTS AND PLANS

1. Respiratory infection/tracheitis. Plan: The patient was discharged on p.o. prednisone taper. Also, hewill continue on the theophylline as an outpatient until his symptoms resolve. He will follow up withme on ___ [DATE]. The patient will also continue on Levaquin for 6 more days as well as his Advairinhaler.

2. Anemia. Plan: The patient's anemia is markedly improved. He does have ulcerative colitis, which hashad a severe flare lately. This is the probable cause of his anemia. We will monitor this as anoutpatient.

3. Ulcerative colitis. Plan: Markedly improved with the Solu-Medrol and prednisone. We will againmonitor this as an outpatient.

HISTORY AND PHYSICAL

CHIEF COMPLAINT: Pneumonia, increased shortness of breath, wheezing, cough, generalized

myalgias, and fevers.

HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old male who was in the clinic both ___

[DATE] as well as ___ [DATE] for pneumonia, increased shortness of breath, wheezing, coughing,

generalized myalgias, and fevers. The patient was started on Rocephin IM. He received 1 gram on ___

[DATE] and another gram on ___ [DATE]. He was noted on ___ [DATE] to have increasing shortness of

breath, increased wheezing. Oxygen saturations were 89% on room air prior to nebulizer treatment.

After nebulizer, was up to 91%. The patient was not laboring at that time with breathing. The patient

was noted to have a mild pale appearance.

The patient was then seen ___ [DATE] evening by Dr. ___ [NAME] and noted to have worsening

shortness of breath, worsening cough, and oxygen saturation was 92%. The patient’s paleness was also

worsened. CBC was drawn and he was notable to be anemic as well as his oxygen saturations were low.

The patient was admitted for hypoxia for further care.

PAST MEDICAL HISTORY: Ulcerative colitis. The patient has recently had a flair and was taking

unknown steroid suppositories for this. He also has a history for anemia.

PAST SURGICAL HISTORY: None.

MEDICATIONS: Only the “steroid suppositories.”

ALLERGIES: None.

SOCIAL HISTORY: The patient does not smoke or drink. He lives at home with his wife and children.

He is a second grade school teacher.

REVIEW OF SYSTEMS: Constitutional: Generalized fatigue and myalgias. HEENT: With headaches,

sore throat, also right eye notable for some erythema and edema, which is worsening in spite of drops.

Cardiovascular: Negative. Respiratory: Shortness of breath, cough, wheeze, lots of sputum production.

Gastrointestinal: Mild upset stomach. No nausea. There has been some diarrhea and vomiting.

Musculoskeletal: Generalized myalgias are noted.

PHYSICAL EXAMINATION: Vital signs: In the clinic, the patient was febrile at 102.1. Blood pressure

138/62, pulse 100, respiratory rate approximately 22. Oxygen saturation in the clinic again, was 92% on

room air. At the time of admission is doing 91% on four liters of oxygen. General: Ill-appearing male.

Pale to ashen gray. HEENT: Ears are clear. Oropharynx is clear. Right eye with obvious erythema and

edema of both conjunctivae as well as the sclerae. Neck: Supple. Lungs: Diffuse rhonchi throughout the

entire lung fields. Heart: Regular rate and rhythm without murmur. Abdomen: Soft and nontender to

palpation. No hepatosplenomegaly is noted. Skin: There is a notable rash on his extremities as well as

his arms, which has just come up recently since his infection.

DIAGNOSTIC STUDIES: Urinalysis was normal. CBC at the time of admission revealed white count of

7.6. Hemoglobin 8.2, hematocrit 24.4. MCV is 79. MCHC 26. His platelets were mildly high at 590,000.

A metabolic panel showed mild low sodium at 128, also low chloride at 97, and a mildly high glucose at

132.

The patient’s blood type is A positive. Also, sputum culture showed gram positive cocci. No growth was

reported.

X-ray reveals questionable diffuse changes. No obvious infiltrate.

EKG is normal.

ASSESSMENT

Hypoxia.1.

Anemia.2.

Ulcerative colitis.3.

Right eye erythema.4.

PLAN

The patient was admitted and started on pneumonia protocol. He was given Levaquin IV 500 mg

q.day, also started on nebulizer treatments as well as on oxygen. We are awaiting the sputum

cultures.

1.

The patient was given two units of whole blood last night. The patient responded well. His CBC

afterwards returned with a hemoglobin 10.7, hematocrit 32.7. The remainder was in the normal

ranges. We will monitor this. It is probably due to patient’s ulcerative colitis.

2.

We will monitor for signs of increased bleeding. X-ray if appropriate.3.

We will consult ophthalmology for further evaluation. He has been placed on two different

ophthalmic antibiotics. Concerned about possible viral versus other condition.

4.

CONSULTATION REPORT

HISTORY OF PRESENT ILLNESS: The patient is a 52-year-old male. He started having respiratory

symptoms the latter part of last week. He was seen in the clinic in ___ [PLACE] by Dr. ___ [NAME] on

___ [DATE] and given a shot of Rocephin. He came back ___ [DATE] and again a shot of Rocephin and

was doing worse. He was directly admitted from the clinic to the hospital. Today he is complaining of

worsening symptoms and shortness of breath. He gets very short of breath if he even tries to walk across

the room. He has a lot of wheezing and a lot of congestion in his lungs but is unable to cough it up. Of

note, the patient was placed on Colazal, a medication for ulcerative colitis, about 2 weeks ago by Dr. ___

[NAME]. The patient feels that his symptoms started about a week after he was placed on that. He is not

sure if there is any correlation between the two.

PAST MEDICAL HISTORY: Previous pneumonia about 10 years ago. He does have a history of

ulcerative colitis. He has had a recent flare, and that is why he was placed on the Colazel. He has been

on Asacol in the past. He has been on steroid suppositories in the past for this problem.

SOCIAL HISTORY: He works as a schoolteacher at an elementary school. He does not smoke tobacco.

No prior surgeries.

MEDICATION ALLERGIES: None.

PHYSICAL EXAMINATION: General: The patient is in obvious respiratory distress. He is sitting up in

the chair and he has labored breathing obvious and audible wheezing from across the room. Vital signs:

Blood pressure 170/90, respirations 24, heart rate 111, temperature 100.7. HEENT: The oropharynx is

clear. Lungs: Diffuse severe wheezing and rhonchi, prolonged expiratory phase. Heart: Tachycardic,

regular rhythm. Abdomen: Soft, no tenderness noted. Extremities: Without any significant edema.

DIAGNOSTIC STUDIES: His blood gas on admission on 28% his PO2 is 62, PCO2 of 35. This is from

the ___ [DATE]. His chemistry profile from this morning is unremarkable other than ALT of 84, AST of

41 and a white count of 9, hemoglobin of 10. He did receive 2 units of blood on admission because his

hemoglobin was 8. He had been having some rectal bleeding from the ulcerative colitis. His differential

a lymphocyte count of 19 and a seg of 70. Cultures done from the ___ [DATE] so far have not grown

anything out of the blood. The sputum just shows 1+ WBCs and scant respiratory flora. X-ray of the

chest from the ___ [NAME] was read as normal.

ASSESSMENTS AND PLANS

Pneumonia, possibly viral. Plan to do a CT scan of the chest today to get a better picture of the

process. He has a lot of bronchospasms and secretions that he cannot cough up. I plan to put him

on guaifenesin and also Solu-Medrol and add Zithromax to his antibiotic coverage to cover more

for atypicals. Also consider broadening coverage for Gram-negatives, although at this point it does

not seem to be a bacterial process that is causing this based on his laboratory data. Aminophylline

will be used intravenously also to help with bronchospasms.

1.

Ulcerative colitis. It does not currently seem to be a problem for him. No rectal bleeding. No

abdominal cramping. The Solu-Medrol he is getting for the lungs will probably help this anyway.

2.

RADIOLOGY REPORT

EXAMS: CT CHEST W/O CONTRAST

INDICATION: History of pneumonia.

TECHNIQUE: Transaxial images of the chest are obtained from apex to base without intravenous contrast.

FINDINGS: No lung infiltrate is seen. The most striking finding is that of a concentric thickening of the wall

of the mid to lower trachea extending into both the right and left bronchi and extending to the hilar regions. This

appears to be essentially a symmetric process and results in severe narrowing of portions of the bronchial tree

particularly the bronchus to the right lower lobe. There is retrocaval and aortopulmonic adenopathy also

observed. Without contrast administration detection of subtle hilar adenopathy is difficult to determine with

certainty.

IMPRESSION

1. Concentric marked thickening of the wall of the mid to lower trachea and right and left bronchi with the wall

up to 9 mm in thickness. See above comments. Differential diagnosis includes tracheal carcinoma (it would be

uncommon to be this extensive), extra medullary myeloma (a rare disease), laryngeal papillomatosis,

amyloidosis, rhinoscleroma, sarcoidosis, tracheopathia osteoplastica, relapsing polychondritis, and Wegener’s

granulomatosis.

2. Though no active lung infiltrate is seen, the bronchial narrowing would certainly predispose to pneumonia

and a recent or recurring pneumonia would not be an unexpected complication of this narrowing.

3. No comparison studies.

PROGRESS NOTE

SUBJECTIVE: ___ [NAME] is feeling much better this morning. He has less breathing problems and much

less anxiety about shortness of breath. He was able to cough up some sputum this morning for us for the first

time actually.

OBJECTIVE: Vital signs: Blood pressure 147/81, respirations 18, heart rate 93, temperature 97. T-max 101.6

yesterday afternoon. Lungs: Diffuse rhonchi and wheezing but less than yesterday and the expiratory phase is

much better, more near normal in length. Heart: Regular rhythm. Abdomen: Soft, nontender.

ASSESSMENT/PLAN

1. Respiratory infection. This appears not to be pneumonia based on CT scan but appears to be a severe case of

tracheal bronchiolitis and seems to be responding to the current therapy. Plan to continue with the steroids,

antibiotics, and theophylline. We also added Decadron to the inhalational treatments. Plan to do a sputum

culture on the specimen he coughed up for us this morning.

2. Ulcerative colitis. This also has improved with high doses of IV steroids.

3. Episcleritis. This might be related to the acute respiratory infection or it might be related to the ulcerative

colitis.

PROGRESS NOTE

SUBJECTIVE: The patient is feeling much better. He has been loosening up sputum, coughing it up very well.

OBJECTIVE: Vital signs: He has been afebrile. Oxygen 04% on room air. Lungs: Just mild wheezing today.

Heart: Regular rhythm.

ASSESSMENT AND PLAN

1. Acute tracheal bronchiolitis, much improved on antibiotics, steroids and inhalers. Plan to continue. Plan to

switch over to oral therapy in anticipation of probably going home tomorrow. The sample that was sent down

to the laboratory yesterday was thought to be tissue and is being sectioned and stained by pathology.

2. Ulcerative colitis. Still having some rectal bleeding. Probably need to use some steroid enemas.

3. Anemia stable.