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PROBLEMS & DIAGNOSES
ALLERGIES
CLINICAL NOTES
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Result type:
Result date:
Result status:
Result title:
Performed by:
Verified by:
Encounter info:
Office/Clinic Note-Physician
April 11, 2010 9:30 PM CDT
Auth (Verified)
Meet Richard Robinson
Grey, Meredith on April 12, 2010 1:34 PM CDT
Grey, Meredith on April 12, 2010 1:34 PM CDT
40000005357, KUMC, Inpatient, 4/11/2010 -
* Final Report *
Your patient, Richard Robinson is a 76 year old gentleman who presented to the emergency department two days ago
with shortness of breath. He states that he ran out of his “water pill” last week and had to wait for his social security check
before he could buy more.
_________________________________________________________________________________
Mr. Robinson has a history of CHF from chronic poorly controlled hypertension. He lives with his oldest son in a senior
citizen apartment. He was in the hospital 1 month ago with similar symptoms.
After discharge, he did well until the middle of last week when he began to notice more exertional dyspnea. Then he
began having shortness of breath at rest. His family took him out to lunch on the day of admission to celebrate his
birthday. He had a great time with his family, but he suspects he may have had too much salt. He cooks for himself and is
always very careful about his salt at home. He says he has gained 15 pounds in the past 2 weeks. His physical function is
slowly declining and he reports difficulty repositioning himself in bed. He is primarily wheel-chair bound but can transfer
with minimal assistance. He has a home health aide who assist with bathing 2x/wk and a nurse who comes daily for
wound care. Mr. Robinson has a stage III sacral ulcer with moderate necrotic tissue.
He was treated in the emergency room, and then admitted with a diagnosis of: Acute exacerbation of CHF related to fluid
overload.
The physician request physical therapy services for wound care management.
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Result type:
Result date:
Result status:
Result title:
Performed by:
Verified by:
Encounter info:
General Radiography Report
April 11, 2010 10:15 PM CDT
Auth (Verified)
Chest X-Ray
Grey, Meredith on April 08, 2010 4:12 PM CDT
Grey, Meredith on April 08, 2010 4:12 PM CDT
40000005357, KUMC, Inpatient, 4/11/2010 -
* Final Report *
FINDINGS -- Limited portable film of the chest shows the cardiomediastinal silhouette, rib cage, hemidiaphragm.
Pulmonary edema noted in both lungs with greater presentation in the left lung.
1. Pumonary edema bilaterally.
Approving Radiologist: Roger Wilkins
Approving Rad Phone #: 9139174358
THIS REPORT WAS RECEIVED FROM AN EXTERNAL RIS SYSTEM
Result type:
Result date:
Result status:
Result title:
Performed by:
Verified by:
Encounter info:
Admission Note-Physician
April 12, 2010 1:00 AM CDT
Auth (Verified)
Admission History and Physical Examination
Grey, Meredith on April 08, 2010 4:06 PM CDT
Grey, Meredith on April 08, 2010 4:09 PM CDT
40000005357, KUMC, Inpatient, 4/11/2010 -
* Final Report *
Admission History and Physical Examination
Patient: Robinson, Richard Edward
MRN: 0070008268
Age: 76 years Sex: Male DOB: 04/05/34
Associated Diagnoses: Pulmonary edema - acute
Author: Grey, Meredith
FIN: 40000005357
Basic Information
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Admit information: Admission Date: 04/11/2010 .
Chief Complaint
SOA and weight gain
History of Present Illness
76 y.o. male with SOA and weight gain. Mr. Robinson has a h/o CHF from chronic poorly controlled HTN. After discharge, he did well until
the middle of last week when he began to notice more exertional dyspnea. His family took him out to lunch on the day of admission to celebrate
his birthday. He had a great time with his family, but he suspects he may have had too much salt. He cooks for himself and is always very
careful about his salt at home. He lives with his oldest son in a senior citizen apartment. He was in the hospital 1 month ago with similar
symptoms.
The patient presents with weight gain. The onset was beginning 2 weeks ago. It is characterized by a 15 lb gain.
The patient presents with shortness of breath. The onset was middle of last week. It is described as breathlessness at rest.
Review of Systems
Constitutional: Fever, Fatigue.
Gastrointestinal: Negative.
Musculoskeletal: Muscle weakness.
Neurologic: weakness and decreased sensation bilaterally L4-S1.
A comprehensive review of systems was negative except for the items noted.
Health Status
Allergies: .
Allergic Reactions (All)
Severity not Documented
Sulfa drugs- No reactions were documented.
Current medications: Patient does not know current medications.
Problem list:
Pulmonary edema
76M w/CAD, CHF, Stage III pressure ulcer, IDDM, HTN.
Histories
Past Medical History: In the hospital 1 month ago with similar symptoms..
Family History: Reviewed; non-contributory.
Procedure History: None noted.
Social History
Alcohol use: none, Social.
Tobacco use: denies tobacco use and exposure.
Drug use.
Occupation: retired.
Family/ Social situation: widowed, living with son, 3 children, Senior citizen apartment.
Education: Some college
Sexually Active: Not on file
Social History Narrative: No narrative on file
Physical Examination
VS/Measurements
Last Filed In 24 Hours Vital Signs: 24 Hour Range
NBP: 83/42 mmHg
Temp: 36.4 °C (100.5 °F)
Pulse: 110
Respiratory: 17 PER MINUTE
SpO2: 99 %
O2 (lpm): 2 LPM (03/15 2340)
O2 Delivery: Nasal Cannula NBP: (71-104)/(31-60)
Pain Scale 0-10: 0
General: No acute distress, alert, confused.
HENT:
Head: Normocephalic, without obvious abnormality.
Neck: Supple, symmetrical.
Respiratory:
Breath sounds: Wheezes present (monophonic).
Cardiovascular: Regular rhythm, Tachycardia.
Gastrointestinal: Soft, Non-distended, No organomegaly, TTP. No masses.
Bowel sounds: Hypoactive.
Rectum/ anus: Normal tone, Prostate ( slightly enlarged ), Hemoccult test ( Positive ), Stool ( in rectal vault ).
Integumentary:
Integumentary exam: Lesion ( Ulcer (Stage III sacral ulcer with 50% necrotic tissue - yellow slough, mild odor) ).
Neurologic:
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Orientation: To person, To place, Not to time.
Altered level of consciousness: Confused.
Extremities: Extremities warm, 3-4 sec cap refill BLE
Health Maintenance
There is no immunization history on file for this patient.
Review / Management
Results review:
24-hour labs:
Results for orders placed during the hospital encounter of 04/11/10 (from the past 24 hour(s))
CBC AND DIFF
Collection Time 4/12/10 22:00 PM
Component Value Range
- White Blood Cells 12.0 (*) 4.5 - 11.0 (K/UL)
- RBC 5.00 4.4 - 5.5 (M/UL)
- Hemoglobin 15.8 13.5 - 16.5 (GM/DL)
- Hematocrit 48.5 40 - 50 (%)
- MCV 96.0 80 - 100 (FL)
- MCH 31.0 26 - 34 (PG)
- MCHC 33.0 32.0 - 36.0 (G/DL)
- RDW 17.9 (*) 11 - 15 (%)
- Platelet Count 245 150 - 400 (K/UL)
- MPV 9.0 7 - 11 (FL)
- Neutrophils 88 (*) 41 - 77 (%)
- Lymphocytes 5 (*) 24 - 44 (%)
- Monocytes 7 4 - 12 (%)
- Eosinophils 0 0 - 5 (%)
- Basophils 0 0 - 2 (%)
- Absolute Neutrophil Count 10.48 (*) 1.8 - 7.0 (K/UL)
- Absolute Lymph Count 0.64 (*) 1.0 - 4.8 (K/UL)
- Absolute Monocyte Count 0.87 (*) 0 - 0.80 (K/UL)
- Absolute Eosinophil Count 0.01 0 - 0.45 (K/UL)
- Absolute Basophil Count 0.01 0 - 0.20 (K/UL)
COMPREHENSIVE METABOLIC PANEL
Collection Time 3/15/10 4:40 PM
Component Value Range
- Sodium 140 137 - 147 (MMOL/L)
- Potassium 5.0 3.5 - 5.1 (MMOL/L)
- Chloride 90 (*) 98 - 110 (MMOL/L)
- Glucose 119 (*) 70 - 100 (MG/DL)
- Blood Urea Nitrogen 69 (*) 8 - 20 (MG/DL)
- Creatinine 9.06 (*) 0.4 - 1.24 (MG/DL)
- Calcium 9.3 9.0 - 11.0 (MG/DL)
- Total Protein 8.8 (*) 6.0 - 8.0 (G/DL)
- Total Bilirubin 0.8 0.3 - 1.2 (MG/DL)
- Albumin 3.6 3.5 - 5.0 (G/DL)
- Alk Phosphatase 99 25 - 110 (U/L)
- AST (SGOT) 234 (*) 7 - 40 (U/L)
- CO2 26 21 - 30 (MMOL/L)
- ALT (SGPT) 170 (*) 7 - 56 (U/L)
- Anion Gap 24 (*) 8 - 12
- eGFR Non African American 6 (*) > >60 (ML/MIN/1.73 SQM)
- eGFR African American 7 (*) > >60 (ML/MIN/1.73 SQM)
PTT (APTT)
Collection Time 3/15/10 4:40 PM
Component Value Range
- APTT 26.3 26.1 - 37.6 (SEC)
LIPASE
Collection Time 3/15/10 4:40 PM
Component Value Range
- Lipase 13 (*) 22 - 51 (U/L)
AMYLASE
Collection Time 3/15/10 4:40 PM
Component Value Range
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- Amylase 61 36 - 128 (U/L)
PROTIME INR (PT)
Collection Time 3/15/10 4:40 PM
Component Value Range
- INR 1.2 (*) 0.9 - 1.1
LACTIC ACID (BG - RAPID LACTATE)
Collection Time 3/15/10 7:42 PM
Component Value Range
- Lactic Acid,BG 1.7 0.5 - 2.0 (MMOL/L)
COMPREHENSIVE METABOLIC PANEL
Collection Time 3/15/10 11:34 PM
Component Value Range
- Sodium 138 137 - 147 (MMOL/L)
- Potassium 5.0 3.5 - 5.1 (MMOL/L)
- Chloride 93 (*) 98 - 110 (MMOL/L)
- Glucose 87 70 - 100 (MG/DL)
- Blood Urea Nitrogen 79 (*) 8 - 20 (MG/DL)
- Creatinine 8.95 (*) 0.4 - 1.24 (MG/DL)
- Calcium 8.4 (*) 9.0 - 11.0 (MG/DL)
- Total Protein 7.6 6.0 - 8.0 (G/DL)
- Total Bilirubin 0.8 0.3 - 1.2 (MG/DL)
- Albumin 3.1 (*) 3.5 - 5.0 (G/DL)
- Alk Phosphatase 89 25 - 110 (U/L)
- AST (SGOT) 203 (*) 7 - 40 (U/L)
- CO2 23 21 - 30 (MMOL/L)
- ALT (SGPT) 175 (*) 7 - 56 (U/L)
- Anion Gap 22 (*) 8 - 12
- eGFR Non African American 6 (*) > >60 (ML/MIN/1.73 SQM)
- eGFR African American 7 (*) > >60 (ML/MIN/1.73 SQM)
Glucose: 87 (04/11/10 21:34)
Blood: Positive (04/11/2010 21:34).
Radiology results
pertinent radiology reviewed
Impression and Plan
Diagnosis
Pulmonary edema - acute (SNMCT 1490485013, Admitting, Medical).
FORM BROWSER
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FLOWSHEET
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ORDERS
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