Consultation Report

CONSULTATION REPORT patient Name: Huy Chong File government issue: 106-23-1025 populate Number: 707 Consultation Date: January 19, 2009 Requesting Physician: Richard T. Dendrite, MD This 31-year-old male of Asiatic descent with a history of hypertension and migraines who was admitted on January 16, 2009 with a change in moral side and was found to pretend a subarachnoid hemorrhage. He had a cutting off of an aneurism on January 7, 2009. Since the clipping his neurological and mental position has been slowly worsening. He began to show designate of vasospasm and a quote CT record showed increased cerebral edema and evidence of an infarction. Today his mental status worsened even more than and he was intubated. We atomic number 18 asked to assist with breathing machine support. PAST MEDICAL history: unprecedented for hypertension and migraines, no other history is known. SOCIAL HISTORY: Significant for existence a smoker. PHYSICAL EXAMINATION: O n testingination he was sedated on a ventilator. His vital signs be stable. He is afebrile. HEENT exam is remarkable for having an oral endotracheal tube. There are no world-shattering secretions from the endotracheal tube. His neck is supple. His lungs are clear bilaterally. His sum has a fixing rate and rhythms without murmurs, rubs, or gallops. Abdomen is dim and non-tender. No abdominal distension or hepatosplenomegaly.

Extremities are without clubbing, cyanosis, or edema. Current ventilator settings are assist/control sit rate of 10, gentle volume 600 cc, and oxygen at 40%. Arterial line of produc ts gas is a ph of 7.46, a PC02 of 35, and a ! PO2 of 179. His knocker x-ray was reviewed and demonstrates clear lung fields with a normal cardiac silhouette. IMPRESSION: 1. Subarachnoid hemorrhage. 2. Status post aneurism clipping. 3. Central sickish system infarct and edema. Continued CONSULTATION REPORT forbearing Name: Huy Chong File Number: 106-23-1025 Page 2 The patient is currently stable from a respiratory standpoint. We will have to deliver him...If you want to get a full essay, value it on our website: OrderCustomPaper.com

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