Patient Report

Patient Report

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FINDINGS: Severe right-sided chest pain. The __ reported a friction rub. A PM lateral showed questionable mediastinal adenopathy. The patient had no cough or sputum production of ___. CT scan in ___ showed a possibility of a 1x2 cm right paratrachial lymphnode. Several smaller anteromediastinal lymphnodes which were all less than 1 cm were also evaluated. The patient was treated with Indocen with relief of her chest pain. ___ level was 64.5 with a ___ 50. PPD was negative, controls were positive. The CT of the abdomen showed normal liver, spleen, pancreas, kidneys, adrenals, uterus, a left ovarian cyst, a large gall stone neck of the gall bladder, no adenopathy and her mammogram was within normal limits. The patient reports band-like ache around her right chest with changes in pain with cough and deep breathing. There is no change in position. The patient reports increased shortness of breath with exertion over the past 5 months. No nausea, vomiting, fevers, chills, night sweats, abdominal pains, urinary complaints, kidney stones, diarrhea, ___ melena, headache, visual complaints or rash.

PAST MEDICAL HISTORY: Unremarkable.

PAST SURGICAL HISTORY: Remarkable for tubal ligation.

SHE HAS NO KNOWN DRUG ALLERGIES.

MEDICINES ON ADMISSION: Indocin 25-50 mg p.o. q.8 hours and Anaprax 270 mg p.o. b.i.d.

The patient drinks alcohol only rarely and smokes regularly.

PHYSICAL EXAMINATION: Weight of 231 pounds, temperature 98.6, heartrate 60, respiratory rate 24, blood pressure 110/70. HEENT examination was unremarkable. The neck was supple without masses, adenopathy or bruits. The lungs showed small diffuse wheezes, but was otherwise without abnormality. Cardiovascular examination revealed a regular rate and rhythm, normal S1 and S2. Questionably slight change in the S1 with the __ maneuver and a questionable 1/6 systolic ejection murmur heard best at the lower sternal border. The abdomen was obese, showed bowel sounds in all quadrants, soft and nontender. It was difficult to tell if there was organomegaly. Extremities showed no clubbing, cyanosis or edema. Neurologically, the patient was normal.

LABORATORY DATA: Show a white count of 8, hemoglobin 14.5, hematocrit 42.5, platelets 326,000, sodium 139, potassium 4.9, chloride 104, CO2 26, glucose 105, creatinine 0.8 and BUN of 17. Please see consolidated lab flow sheet for lab data regarding this patient.

HOSPITAL COURSE: Patient was admitted in ____ evaluations as well as consultation from pulmonology service. Pulmonology service recommended the patient undergo bronchoscopy which was performed.

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The patient had the procedure performed on ___ without complication. Biopsies were negative with negative cultures as well. The patient also underwent pulmonary function testing performed on ___ done without complications. The patient also underwent thin-cut CT of the chest and abdomen as well as cardiac echocardiography and overnight desaturation studies. All of these were performed on___ without complication. The thin-cut CT of the chest showed no evidence of adenopathy. It was suspicious for pathology and her abdominal series was normal. Cardiac cardiography demonstrated the patient did have pulmonary hypertension, but the mean pulmonary arteriopressure of about 45 mm mercury. The patient was also steady with an overnight desaturation monitor which failed to demonstrate significant periods of apnea. The patient was therefore felt not to have any mediastinal adenopathy and the patient was told that her pulmonary function was probably a result of chronic tobacco abuse and that the best recommendations for her were to stop smoking in a ___ controlled program. The patient agreed with these recommendations and was discharged to home in an unchanged condition.

DISCHARGE DIAGNOSES:
1. Hypertension.
2. Tobacco abuse.
3. Obesity.
4. Ovarian cyst.
5. Cholelythiasis.

Saturation study: No complications.

DISCHARGE MEDICATIONS:
1. Indocin 25 mg p.o. t.i.d.

DISPOSITION: The patient is discharged to ____ to return to the care of her primary physician and to begin smoking cessation and weight reduction programs which will benefit her pulmonary status.
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