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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:
PET Report
April 12, 2010 2:25 PM CDT
Auth (Verified)
PET Scan
Grey, Meredith on April 08, 2010 12:23 PM CDT
Grey, Meredith on April 08, 2010 12:23 PM CDT
40000005356, KUMC, Inpatient, 4/12/2010 -
* Final Report *
There is physiologic uptake of F-18 tracer seen within the brain, heart, kidneys, bladder, and bowel.
There is a right chest port in place. Postsurgical changes of a previous left sentinel node biopsy with left
mastectomy are noted.
There is no metabolic activity in the cervical, thoracic and lumbosacral areas.
IMPRESSION:
1. No change since prior scan. No metastatic activity noted.
Approving Radiologist: Roger Wilkins
Approving Rad Phone #: 9139174358
THIS REPORT WAS RECEIVED FROM AN EXTERNAL RIS SYSTEM
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Result type:
Result date:
Result status:
Result title:
Performed by:
Verified by:
Encounter info:
Admission Note-Physician
April 12, 2010 3:02 PM CDT
Modified
Physician Note
Grey, Meredith on April 08, 2010 11:23 AM CDT
Grey, Meredith on April 08, 2010 12:24 PM CDT
40000005356, KUMC, Inpatient, 4/12/2010 -
* Final Report *
Document Has Been Updated
Physician Note
Patient: Rigles, Dee Elizabeth
MRN: 0070008267
Age: 64 years Sex: Female DOB: 02/15/46
Associated Diagnoses: Syncope; DIABETES MELLITUS
Author: Grey, Meredith
FIN: 40000005356
Visit Information
Source of history: Self, Family member (daughter), Medical record.
Chief Complaint
Syncope
History of Present Illness
The course is Clinical improvement with pain management and physical therapy. Admit to oncology for further management
.
64 y/o female with a h/o IDDM, Breast Cancer s/p modified mastectomy with chemo and radiation treatment 05/2009, presents today due to syncope
and c/o LBP.
Review of Systems
Constitutional: Fatigue, activity change.
Ear/Nose/Mouth/Throat: No rhinorrhea, No neck pain, No neck stiffness, No sinus pressure, No ear pain, No sore throat.
Respiratory: No shortness of breath, No cough.
Cardiovascular: No chest pain, No leg swelling.
Gastrointestinal: No vomiting, No diarrhea, No abdominal pain.
Genitourinary: Negative.
Hematology/Lymphatics: Negative.
Integumentary: Negative, Visible mastectomy scar in left breast area.
Neurologic: Negative.
Psychiatric: Negative.
Sensation: Decreased in both lower extremties L4-S1.
Health Status
Allergies: .
Allergic Reactions (All)
Severity not Documented
Penicillin- Hives and rash.
Current medications: ,
Medication Orders
oxycodone, 20 mg, Tab, PO, q4hr 1 day(s), Stop date 04/13/10 13:24:00 CDT, Routine, Start date 04/12/10 13:25:00 CDT, every 4-6 hrs
CAPD - with 2.5% glucose; 4.0 KCL dialysate solution is planned with three exchanges per day with 8 hour dwell times Exchange: 4/12/2010
1415
.
Histories
Past Medical History:
Nursing Medical History
- Cancer Yes L Breast Cancer
- Kidney Failure Yes peritoneal hemodialysis
- Diabetes Yes
Diagnosis Date
- Type II Diabetes Mellitus with peripheral neuropathy and retinopathy
- End Stage Renal Disease
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
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- Renal Failure
- Obesity
- Peritoneal Dialysis
- Personal History of Breast Cancer.
Family History: No family history on file.
Procedure History:
Nursing Surgical History
- Other Yes mastectomy left 2009
Procedure Date
- Hx breast mastectomy, left with SNB.
Social History
Alcohol use: occasional (small amt).
Tobacco use: denies tobacco use and exposure.
Denies Drug use.
Physical Examination
VS/Measurements
Filed Vitals:
04/12/2010 1:46 PM 04/12/2010 2:02 PM 04/12/2010 2:31 PM 04/12/2010 2:46 PM
BP: 159/52 170/72 153/64 171/54
Pulse: 71 84 88 77
Temp:
Weight:
SpO2: 98% 92% 97% 98%
Pain assessment:
Self-reports pain
Numeric rating: 8 / 10 on the severity scale (Wong-Baker Pain Scale).
.
General: Alert and oriented, Moderate distress.
Appearance: Well nourished, Well developed.
Signs of distress: Tachypnic, at times unable to speak in complete sentences
.
Skin: Not diaphoretic
.
Eye:
Pupil: Equal, reactive to light
, round
.
Extraocular movements: normal
.
HENT:
Head: Hair/scalp ( Normocephalic and atraumatic
).
Neck: Full range of motion, supple
, No jugular venous distention.
Respiratory:
Respirations: Tachypneic.
Breath sounds: No rales present, No wheezes present.
Cardiovascular: Normal rate, Regular rhythm.
Gastrointestinal: Soft, Non-tender, Non-distended.
Lymphatics:
Lymphatic exam: no cervical adenopathy
.
Musculoskeletal: no edema
.
Integumentary: Warm, Dry, not diaphoretic
.
Neurologic: Alert, Oriented, normal muscle tone
.
Psychiatric:
Mood and affect: normal
.
Behavior: normal
.
Review / Management
Results review:
Results for orders placed during the hospital encounter of 04/12/10 13:25 (from the past 24 hour(s))
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
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© KU Center for Health Informatics | Page 5 of 13
CBC AND DIFF
Component Value Range
- White Blood Cells 6.1 4.5 - 11.0 (K/UL)
- RBC 2.90 (*) 4.0 - 5.0 (M/UL)
- Hemoglobin 8.6 (*) 12.0 - 15.0 (GM/DL)
- Hematocrit 26.7 (*) 36 - 45 (%)
- MCV 92.0 80 - 100 (FL)
- MCH 30.0 26 - 34 (PG)
- MCHC 32.0 32.0 - 36.0 (G/DL)
- RDW 18.9 (*) 11 - 15 (%)
- Platelet Count 224 150 - 400 (K/UL)
- MPV 9.0 7 - 11 (FL)
- Neutrophils 91 (*) 41 - 77 (%)
- Lymphocytes 2 (*) 24 - 44 (%)
- Monocytes 5 4 - 12 (%)
- Eosinophils 2 0 - 5 (%)
- Basophils 0 0 - 2 (%)
- Absolute Neutrophil Count 5.58 1.8 - 7.0 (K/UL)
- Absolute Lymph Count 0.10 (*) 1.0 - 4.8 (K/UL)
- Absolute Monocyte Count 0.29 0 - 0.80 (K/UL)
- Absolute Eosinophil Count 0.09 0 - 0.45 (K/UL)
- Absolute Basophil Count 0.00 0 - 0.20 (K/UL)
COMPREHENSIVE METABOLIC PANEL
Component Value Range
- Sodium 120 (*) 137 - 147 (MMOL/L)
- Potassium 4.4 3.5 - 5.1 (MMOL/L)
- Chloride 111 (*) 98 - 110 (MMOL/L)
- Glucose 159 (*) 70 - 100 (MG/DL)
- Blood Urea Nitrogen 145 (*) 8 - 20 (MG/DL)
- Creatinine 1.33 (*) 0.4 - 1.00 (MG/DL)
- Calcium 9.2 9.0 - 11.0 (MG/DL)
- Total Protein 6.0 6.0 - 8.0 (G/DL)
- Total Bilirubin 0.8 0.3 - 1.2 (MG/DL)
- Albumin 2.9 (*) 3.5 - 5.0 (G/DL)
- Alk Phosphatase 116 (*) 25 - 110 (U/L)
- AST (SGOT) 19 7 - 40 (U/L)
- CO2 16 (*) 21 - 30 (MMOL/L)
- ALT (SGPT) 12 7 - 56 (U/L)
- Anion Gap 8 8 - 12
- eGFR Non African American 40 (*) > >60 (ML/MIN/1.73 SQM)
- eGFR African American 48 (*) > >60 (ML/MIN/1.73 SQM)
PROTIME INR (PT)
Component Value Range
- INR 1.2 (*) 0.9 - 1.1
PTT (APTT)
Component Value Range
- APTT 45.4 (*) 26.1 - 37.6 (SEC)
BLOOD GASES -ARTERIAL
Component Value Range
- pH -Arterial 7.41 7.35 - 7.45
- pCO2 -Arterial 29 (*) 33 - 48 (MMHG)
- pO2 -Arterial 118 (*) 80 - 90 (MMHG)
- Base Deficit -Arterial 5.6 (MMOL/L)
- O2 Sat -Arterial 98.8 95 - 99 (%)
- Bicarbonate -ART -Cal 18.2 (MMOL/L)
TROPONIN -I
Component Value Range
- Troponin -I 0.02 0.0 - 0.05 (NG/ML)
Urine Dipstick
- Urine Glucose: Negative
- Bilirubin: Negative
- Ketone: Negative
- Specific Gravity: 1.020
- Blood: 1+
- pH: 5.5
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- Protein: 2+
- Urobilinogen: Normal 0.2 mg/dl
- Nitrate: Negative
- Leukocytes: Negative
- Color: Yellow
- Turbidity: Clear
- Urine Dipstick Lot #: 9L11CBA
.
Radiology results
X-ray (Chest: No fractures noted. Moderate DDD in C4-C6 and L1-L4)
ECG interpretation: Sinus, no STE, poor R wave progression
.
Documentation reviewed: Reviewed prior records.
PET Scan: Insignificant.
Impression and Plan
Diagnosis
Syncope (ICD9 780.2, Admitting, Medical).
DIABETES MELLITUS (ICD9 250, Admitting, Medical).
V10.3 History of Breast Malignancy (personal hx).
Professional Services
MDM Coding:
Reviewed: previous chart, vitals and nursing note
Review previous: labs
Interpretation: labs, ECG, PET Scan, and x-ray
Result type:
Result date:
Result status:
Result title:
Performed by:
Verified by:
Encounter info:
Discharge Note-Physician
April 14, 2010 10:25 AM CDT
Auth (Verified)
Discharge Summary
Sabus, Carla on October 22, 2010 1:41 PM CDT
Sabus, Carla on October 22, 2010 1:41 PM CDT
40000005356, KUMC, Inpatient, 4/12/2010 -
* Final Report *
atient: Rigles, Dee Elizabeth
MRN: 0070008267
Age: 64 years Sex: Female DOB: 02/15/46
Associated Diagnoses: Syncope; DIABETES MELLITUS
Author: Grey, Meredith
FIN: 40000005356
Visit Information
Source of history: Self, Family member (daughter), Medical record.
Chief Complaint
Syncope
History of Present Illness
64 y/o female with a h/o IDDM, Breast Cancer s/p modified mastectomy with chemo and radiation treatment 05/2009, admitted on 4/12 with syncope
and low back pain.
Review of Systems
Constitutional: Fatigue, ambulating ad lib
Ear/Nose/Mouth/Throat: No rhinorrhea, No neck pain, No neck stiffness, No sinus pressure, No ear pain, No sore throat.
Respiratory: No shortness of breath, No cough.
Cardiovascular: No chest pain, No leg swelling.
Gastrointestinal: No vomiting, No diarrhea, No abdominal pain.
Genitourinary: Negative.
Hematology/Lymphatics: Negative.
Integumentary: Negative, Visible mastectomy scar in left breast area.
Neurologic: Negative.
Psychiatric: Negative.
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
Proprietary Statement: This document contains proprietary information of the University of Kansas School of Nursing. Such proprietary information may not be used,
reproduced, or disclosed to any other parties for any other purpose without the expressed written permission of University of Kansas School of Nursing.
© KU Center for Health Informatics | Page 7 of 13
Sensation: Decreased in both lower extremties L4-S1.
Health Status
Allergies: .
Allergic Reactions (All)
Severity not Documented
Penicillin- Hives and rash.
Current medications: ,
Medication Orders
oxycodone, 20 mg, Tab, PO, q4hr 1 day(s), Stop date 04/13/10 13:24:00 CDT, Routine, Start date 04/12/10 13:25:00 CDT, every 4-6 hrs
CAPD - with 2.5% glucose; 4.0 KCL dialysate solution is planned with three exchanges per day with 8 hour dwell times Exchange: 4/12/2010
1415
.
Histories
Past Medical History:
Nursing Medical History
- Cancer Yes L Breast Cancer
- Kidney Failure Yes peritoneal hemodialysis
- Diabetes Yes
Diagnosis Date
- Type II Diabetes Mellitus with peripheral neuropathy and retinopathy
- End Stage Renal Disease
- Renal Failure
- Obesity
- Peritoneal Dialysis
- Personal History of Breast Cancer.
Family History: No family history on file.
Procedure History:
Nursing Surgical History
- Other Yes mastectomy left 2009
Procedure Date
- Hx breast mastectomy, left with SNB.
Social History
Alcohol use: occasional (small amt).
Tobacco use: denies tobacco use and exposure.
Denies Drug use.
Physical Examination
VS/Measurements
Filed Vitals:
04/14/2010 9:46 AM
BP: 141/73 Pulse: 71 84 88 77
Temp:36.5C
SpO2: 98%
Pain assessment:
Self-reports pain
Numeric rating: 2 / 10 on the severity scale (Wong-Baker Pain Scale).
.
General: Alert and oriented, no distress.
Appearance: Well nourished, Well developed.
Skin: Not diaphoretic
Eye:
Pupil: Equal, reactive to light
, round
.
Extraocular movements: normal
.
HENT:
Head: Hair/scalp ( Normocephalic and atraumatic
).
Neck: Full range of motion, supple
, No jugular venous distention.
Respiratory:
Respirations: Tachypneic.
Breath sounds: No rales present, No wheezes present.
Cardiovascular: Normal rate, Regular rhythm.
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
Proprietary Statement: This document contains proprietary information of the University of Kansas School of Nursing. Such proprietary information may not be used,
reproduced, or disclosed to any other parties for any other purpose without the expressed written permission of University of Kansas School of Nursing.
© KU Center for Health Informatics | Page 8 of 13
Gastrointestinal: Soft, Non-tender, Non-distended.
Lymphatics:
Lymphatic exam: no cervical adenopathy
.
Musculoskeletal: no edema
.
Integumentary: Warm, Dry, not diaphoretic
.
Neurologic: Alert, Oriented, normal muscle tone
.
Psychiatric:
Mood and affect: normal
.
Behavior: normal
.
Assessment and Plan
Diagnosis
SYNCOPE (ICD9 780.2, Admitting, Medical): no cardiac abnormatility; BP stable with current management
DIABETES MELLITUS (ICD9 250, Admitting, Medical).
V10.3 History of Breast Malignancy (personal hx), BS stable with current regime
FALLS, PT/OT consulatation with education and equipment recommendations; f/u with home safety assessment
DISCHARGE to home with visiting RN service, home PT/OT home assessment; f/u in my office in 6 weeks.
FORM BROWSER
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© KU Center for Health Informatics | Page 9 of 13
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FLOWSHEET
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© KU Center for Health Informatics | Page 11 of 13
DISCLAIMER: All patient information appearing on this document is fictitious. Any resemblance to real persons, living or dead, is purely coincidental.
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ORDERS
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© KU Center for Health Informatics | Page 13 of 13