Emergency Room Summary

Eighty-two years old male patient is presented to the emergency room with onset of dyspnea that is made worse by exertion, relieved by rest and oxygen. Patient stated that he did not try any of his home breathing treatments but did use home oxygen. Patient has a significant past medical history of coronary artery disease with two stents, COPD requiring home oxygen at 4lpm, hypothyroidism, and type 3 diabetes. While in the emergency department the patient was placed on a cardiac monitor and an EKG was performed along with a chest x-ray. The chest x-ray showed bilateral lower right and middle left lobe pneumonia. Lactate level 2.2, white blood cell count 3.1 with 83% neutrophils and no bands. BNP 96.7. Urinalysis shows UTI.
Community-acquired pneumonia (CAP) as defined in N. Garin’s article “Predictors and Implications of Early Clinical Stability in Patients Hospitalized for Moderately Severe
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Final impression found mildly dilated left ventricle with normal wall thickness and normal systolic function with an estimated ejection fraction is fifty to fifty-five percent. Thickened mitral valve with mild to moderate aortic stenosis and mild regurgitation is also present with an aortic valve area of 2.0 cm2 and a mean gradient of 11mmHg. Lastly mild left atrial and right atrium enlargement.
The patient also had a White Blood Cell Local Study NM which is an imaging test that uses a radioactive material. How it works is that blood is drawn from the vein and the white blood cells are separated from the rest of the blood sample and then mixed with a small amount of indium-111. The tagged white blood cells are injected back into the body through a vein and the cells will gather in areas of inflammation or infection and scans will be taken three hours’

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