CHIEF COMPLAINT: Amyotrophic lateral sclerosis, 4-week followup.
SUBJECTIVE: The patient is a very pleasant, unfortunate (XX)-year-old male with Lou Gehrig’s disease, who we are seeing here at his house for followup of his numerous concerns.
He has ventilator-dependent respiratory failure. He has had no hypoxia. He has had no fevers or chills. He has tracheostomy that was changed on MM/DD/YYYY without any complications. He also has a history of numerous decubitus wounds in relation to his chronic debilitated state.
He is using a Clinitron bed. Wound measurements are documented in the prior note. He does have chronic edema as well related to anasarca. He also has excessive secretions, on scopolamine patch. His wife states it is worsened with humid weather.
OBJECTIVE:
VITAL SIGNS: He is afebrile at 98.6. Blood pressure 100/64, pulse 66, pulse ox 100% on his current ventilator settings.
GENERAL: He is resting comfortably in bed. He is awake and alert and is nonverbal.
HEENT: Atraumatic. His extraocular muscles are intact. His mucous membranes are moist. Dentition is poor. Oropharynx cannot be visualized.
NECK: Decreased range of motion. Tracheostomy site is clean, dry and intact. No surrounding erythema. No JVD or bruits. No supraclavicular or cervical adenopathy.
HEART: Regular rate and rhythm without murmurs, rubs or thrills.
LUNGS: He has some coarse breath sounds throughout anteriorly at the bases. Unlabored respirations.
ABDOMEN: Soft and nontender. It is nondistended. No hepatosplenomegaly. His PEG site is clean, dry and intact and functioning.
EXTREMITIES: No clubbing or cyanosis. He has chronic venous insufficiency and anasarca of the extremities.
NEUROLOGIC: He has chronic contractures in part in the distal interphalangeal joints of the hands as well as he is chronically in plantarflexion of the feet. He is very rigid with no muscle motion.
PSYCHIATRIC: He smiles, but his affect is flat at times and unable to assess memory as he is nonverbal.
SKIN: See prior note from MM/DD/YYYY.
ASSESSMENT:
1. Amyotrophic lateral sclerosis.
2. Ventilator-dependent respiratory failure via tracheostomy.
3. Generalized anxiety disorder.
4. Chronic pain.
5. Enteral feedings.
6. Chronic allergic rhinitis.
7. Decubitus ulcers.
8. Gastroesophageal reflux disease.
PLAN: The patient frankly is doing very well. All things considered, he seems very stable. We will continue on his medications. We gave him refills on diazepam, fentanyl and methadone. We will also write for prescriptions for omeprazole and lactulose. We will see him back in 4 weeks, sooner for problems, issues or concerns or anything that rises in the interim.
