University of Kansas Medical Center



PROBLEMS & DIAGNOSESALLERGIESCLINICAL NOTESResult type:PET ReportResult date:April 12, 2010 2:25 PM CDTResult status:Auth (Verified)Result title:PET ScanPerformed by:Grey, Meredith on April 08, 2010 12:23 PM CDTVerified by:Grey, Meredith on April 08, 2010 12:23 PM CDTEncounter info: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 WilkinsApproving Rad Phone #: 9139174358THIS REPORT WAS RECEIVED FROM AN EXTERNAL RIS SYSTEMResult type:Admission Note-PhysicianResult date:April 12, 2010 3:02 PM CDTResult status:ModifiedResult title:Physician NotePerformed by:Grey, Meredith on April 08, 2010 11:23 AM CDTVerified by:Grey, Meredith on April 08, 2010 12:24 PM CDTEncounter info:40000005356, KUMC, Inpatient, 4/12/2010 - * Final Report *Document Has Been UpdatedPhysician Note Patient: Rigles, Dee Elizabeth MRN: 0070008267 FIN: 40000005356 Age: 64 years Sex: Female DOB: 02/15/46 Associated Diagnoses: Syncope; DIABETES MELLITUS Author: Grey, Meredith 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 DocumentedPenicillin- Hives and rash. Current medications: , Medication Ordersoxycodone, 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 hrsCAPD - 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: 04/12/2010 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)) 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 - 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 noteReview previous: labsInterpretation: labs, ECG, PET Scan, and x-ray Result type:Discharge Note-PhysicianResult date:April 14, 2010 10:25 AM CDTResult status:Auth (Verified)Result title:Discharge SummaryPerformed by:Sabus, Carla on October 22, 2010 1:41 PM CDTVerified by:Sabus, Carla on October 22, 2010 1:41 PM CDTEncounter info:40000005356, KUMC, Inpatient, 4/12/2010 - * Final Report *atient: Rigles, Dee Elizabeth MRN: 0070008267 FIN: 40000005356 Age: 64 years Sex: Female DOB: 02/15/46 Associated Diagnoses: Syncope; DIABETES MELLITUS Author: Grey, Meredith 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. Sensation: Decreased in both lower extremties L4-S1. Health Status Allergies: . Allergic Reactions (All)Severity not DocumentedPenicillin- Hives and rash. Current medications: , Medication Ordersoxycodone, 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 hrsCAPD - 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 diaphoreticEye: 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. 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 regimeFALLS, PT/OT consulatation with education and equipment recommendations; f/u with home safety assessmentDISCHARGE to home with visiting RN service, home PT/OT home assessment; f/u in my office in 6 weeks. FORM BROWSER FLOWSHEETORDERS ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download