Consultation Report

CONSULTATION REPORT

patient Name: Huy Chong
File Number: 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 status and was found to pretend a subarachnoid hemorrhage. He had a clipping of an aneurism on January 7, 2009. Since the clipping his neurological and mental status has been slowly worsening. He began to show evidence of vasospasm and a repeat CT record showed increased cerebral edema and evidence of an infarction. Today his mental status worsened even more and he was intubated. We atomic number 18 asked to assist with ventilator support.

PAST MEDICAL history: unprecedented for hypertension and migraines, no other history is known.

SOCIAL HISTORY: Significant for being a smoker.

PHYSICAL EXAMINATION: On examination 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 significant secretions from the endotracheal tube. His neck is supple. His lungs are clear bilaterally. His sum has a regular 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, title volume 600 cc, and oxygen at 40%. Arterial blood gas is a ph of 7.46, a PC02 of 35, and a PO2 of 179. His chest 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 nervous system infarct and edema.

Continued

CONSULTATION REPORT
Patient Name: Huy Chong
File Number: 106-23-1025
Page 2

The patient is currently stable from a respiratory standpoint. We will need to deliver him...If you want to get a full essay, order it on our website: Orderessay



If you want to get a full essay, wisit our page: write my essay .