MS-III PROGRESS NOTE
Signed: 01/28/2004 14:08
S: HD#5. Antibiotic Day #14 Total (Day 5 Cefipime and finished Azythro.)
Mr. Frier reports a good night. He states that he slept most of the day and
night after his bronchoscopy. He continues to have occasional hemoptysis and
mild SOB. No CP, dizziness, muscle twitches, or confusion.
O: T:98.4 F P: 85 (BRACHIAL) R:20 (SPONTANEOUS) B/P:124/75
Pulse Oximetry: 98% with supplemental O2 2L/min via NASAL CANNULA
Pain: 0 - No pain
Gen-Pleasant. Alert and oriented to person, place, and time.
Derm- Mild tenting. Lower extremity skin is scaling.
CV- No JVD. RRR. Nl S1 S2. No murmurs, gallops or rubs.
Pulm- Slight rales at left base.
Ext- No cyanosis, clubbing, or edema.
Labs:
Test name
WBC
RBC
HGB
HCT
MCV
MCH
MCHC
PLT
RDW-SD
RDW
MPV
GRAN #
LYMPH #
MONO #
EOSINO #
BASO #
GRAN %
LYMPH %
MONO %
EOSINO %
BASO %
GLUCOSE
UREA NITROGEN
CREATININE
SODIUM
POTASSIUM
CHLORIDE
CO2
PO4
ANION GAP
CALCIUM
MAGNESIUM
Specimen: URINE.
Test name
URINE COLOR
CLARITY
SPECIFIC GRAVITY
URINE PH
URINE PROTEIN
URINE GLUCOSE
URINE KETONES
URINE BILIRUBIN
URINE BLOOD
URINE NITRITE
UROBILINOGEN(EU/dL)
LEU ASE
URINE RBC/HPF
URINE WBC/HPF
URINE EPITH CELLS
Result
14.72 H
4.58
13.3 L
37.9 L
82.8
29.0
35.1
387
36.7 L
12.2
8.5
12.50 H
1.14 L
1.01 H
0.06
0.01
84.9 H
7.7 L
6.9
0.4
0.1
80
9
0.6
120 L
4.0
81 L
20 L
2.5
19 H
8.9
1.9
units
k/cmm
M/cmm
g/dL
%
um3
pg
g/dL
k/cmm
fL
%
um3
k/cmm
k/cmm
k/cmm
k/cmm
k/cmm
%
%
%
%
%
mg/dL
mg/dL
mg/dL
mmol/L
mmol/L
mmol/L
mmol/L
mg/dL
mmol/L
mg/dL
mg/dL
UR 0124 1
01/24/2004 07:58
Result
units
AMBER
SLHAZY
1.026
5.5
NEG
mg/dL
TR
mg/dL
40
NEG
LG
NEG
0.2
EU/dL
NEG
42
/HPF
6
/HPF
<1
Ref.
4.6
4.44
13.9
41
80
27
31.8
130
39
11.5
7.4
1.8
1.2
.14
0
0
54
25
3
0
0
65
9
.5
135
3.5
98
23
2.5
5
8.4
1.7
Ref.
-
range
10.8
6.1
18
52
98
33.3
37.1
440
52.2
14.5
10.5
7.8
3.6
.76
.3
.2
65
33
7
3
2
109
20
1.2
145
5
108
32
4.6
15
10.5
2.5
range
1.003 - 1.03
5 9
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
NEGATIVE
.2 1
NEGATIVE
A/P: Mr. Frier was admitted with symptoms of dyspnea and unresolved
pneumonia. He has remained afebrile since admission and sputum culture has no
growth to date. CT scan revealed post-obstructive pneumonia, lung mass,
extensive adenopathy, and liver densities suspicious for metastases. Patient
underwent bronchoscopy yesterday and final report is pending. He has been
hyponatremic since 1/13/2004. Current labs reveal Mr. Frier has acheived a serum
sodium of 120 after receiving normosaline, indicating. His chronic hyponatremia
may be due to SIADH activity from small cell carcinoma. He has no mental status
changes or signs of edema.
1.
2.
3.
4.
5.
6.
Pneumonia- postobstructive
Lung mass
Hyperlipidemia
Hyponatremia
Hypochloremia
COPD
1. Pulm- Contiue Chest PT, continue Nebulizer treatment. Awaiting cytology
results.
2. FEN- Still hyponatremic. Concentrated urine and low osmolality indicate possible
SIADH. Awaiting lab arginine vasopressin. After results, consider starting demeclocycline
600-1200mg/day to block action of ADH. Renal consult. Continue to monitor for mental
status changes and edema. Continue to restrict fluids.
3: ID Continue Cefipime 1 g Q12 Day 5 for treatment of pneumonia. Monitor for
clinical progress of pneumonia.
4. CVS: no active issues at this time, continue asa, continue simvistatin
/es/ DEBORAH A CHASE
MS-III