Inpatient Consultation
Patient Case Number: IPC41-Hendrix, Paul
Patient Name: Paul Hendrix | DOB: 07-11-60 | Sex: M
Date of Service: 04-28-XX | Physician: Christopher Wills, MD

# Reason for Consultation: Evaluation for removal peg tube, decannulation

# History of Present Illness:

Pt is well known to trauma service- now readmitted for L BKA from rehab. Pt had undergone PEG and Trach in February. Pt is no longer using PEG tube for meds or feeds and pt is tolerating trach plugged. No further surgeries planned.

# Medical History: DMII, GERD

# Surgical History: Exploratory laparotomy and External fixation femur fracture, PEG tube placement, tracheostomy placement

# Hospital Medications: Peridex, Colace, Lovenox, Iron, Lantus, Humalog, Robaxin, Lopressor, Protonix, Trazodone, Tylenol, Dulcolax, Proventil, Dilaudid, Zofran, Oxycodone, Robitussin, Omeprazole

# Review of Systems: See HPI for pertinent positives

# Vitals:

Temperature | 98.6°F
Pulse | 110
Respirations | 17
Blood Pressure | 130/70
SpO2 | 96% on room air

# Physical Examination

# Constitutional: He is oriented to person, place, and time. He appears well developed and well-nourished. No distress.

# HENT

# Head: Normocephalic.

# Eyes: Conjunctivae are normal.

# Neck: Normal range of motion. Neck supple. Metal trach w/ plug intact - phonating well

# Cardiovascular: Normal rate and regular rhythm. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. Abdominal: Soft. Bowel sounds are normal. He exhibits no distension. There is no tenderness. Well healed midline abd incision, +peg tube - site clean and dry Musculoskeletal: L BKA - stump dressing intact +tenderness. RLE splinted Neurological: He is alert and oriented to person, place, and time.

# Skin: Skin is warm and dry.

# Psychiatric: He has a normal mood and affect. His behavior is normal.

# Assessment:

1. I pulled pt’s PEG tube and decannulated pt. Occlusive dressings applied to both anterior neck and abdomen. Maintain for 24hrs.

2. Diabetes mellitus

3. GERD

# Plan:

No discharge today per trauma - anticipate pt will return to rehab given new L BKA

# Electronically Signed By: Christopher Wills, MD

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