I need HELP!!
Has anyone recently worked on this report and would be able to help me out? I would really appreciate it! Thanks
PAST MEDICAL HISTORY
Patient was status post for "tubal" basal stroke which left him with gait unsteadiness. He had a known history of peptic ulcer disease and diverticular disease.

MEDICATIONS
1. Protonix 40 mg q.d.
2. "Hydrangea" 4 mg q.d.

ALLERGIES
None known.

PHYSICAL EXAM
We have a " " appearing outgoing man _______. Pulse 70 regular. Blood pressure 140/82.

listen for "vertebrobasilar stroke."

"Avandia 4 mg q.d."

Thanks for your help! Now I'm stuck on the laboratory part:

LABORATORY
Hemoglobin 13, hematocrit 39.2, WBC 8.1, platelets 330,000. Chemistry: Sodium 133, potassium 4.6, chloride 98, CO2 30, glucose 102, BUN 22, creatinine 1.1. Ascitic fluid abdomen was 2.5. Cell count was 677. Protein was 4.1. CEO was 2.5. PSO was 2.77. Alpha-fetoprotein was 2.3. Urine culture was negative. Ascitic fluid cultures were negative. CA1919 was 58.

Not sure if my punctuation is correct, too??

You may want to ckeck the lab section on "Ascitic fluid:", look up ascitic fluid albumin level. Check to see which items should be included in the "Ascitic fluid:" group. Also check the tumor markers (CEO) and (PSO). I get lots of help from Wikipedia. It covers lots of topics, is very readable and concise. I keep the Wiki pages on Abbreviations and Normal lab values on my favorites bar.

Hope this helps.

PAST MEDICAL HISTORY
The patient was status post for vertebrobasilar stroke, which left him with a gait unsteadiness. He had a known history of peptic ulcer disease and diverticular disease.

MEDICATIONS
Protonix 40 mg daily, Avandia 4 mg daily.

LABORATORY
Hemoglobin 13, hematocrit 39.2, WBC 8.1, platelets 330,000. Chemistry: Sodium 133, potassium 4.6, cholride 98, CO2 30, glucose 102, BUN 22, Creatinin3e 81.1. Ascitic fluid: Albumin was 2.5, cell count was 677, protein was 4.1, CEA was 2.5. PSA was 2.77. Alpha-fetoprotein was 2.3. Urine culture was negative. Ascitic fluid culture were negative, CA-1919 was 58.

Hope this helps.

Danita

PHYSICAL EXAM
Physical exam revealed a frail-appearing elderly man. Vital signs: Pulse 70, regular. Blood pressure 140/82. Temperature 96.7. Skin: No Pallor. HEENT: No scleral icterus. Neck: Without goiter. No carotid bruits. Lungs clear. Heart: Systolic ejection murmur. Abdomen distended. Positive fluid wave. No masses. Rectal was negative.

Can anyone help me with this? I just had a baby and have been away from my homework for so long that I'm sure I made many mistakes but I'm just not seeing them. Thank you too anyone that can help me out with even one mistake.



PROBLEM LIST
1. Acities
2. Diverticular disease
3. Peptic ulcer disease
4. Type two Diabetes mallitus
5. Status post Stroke

Brief History
Ninety-one-year-old white male was admitted to the hospital due to weakness, fatigue anorexia and a distended abdomen. The patient had a history of known peptic ulcers disease. He had been admitted in November with acute diverticulitis.

For several weeks the patient had been experiencing anorexia and mild nausea. For several days his abdomen appeared to becoming increasingly more distended and with these symptoms he was brought to the emergency room.

CT scan in the emergency room revealed a large amount of acities, there was a left renal cyst, there was, thought to be, changes in the mesinary are consistent peritaneal carcinomatosis there were multiple hypo densities in both kidneys thought to reprasent

Past Medical History

The Patient was status post for vertebrobasilar stroke, which left him with a gait unsteadiness. He had a known history of peptic ulcer disease and diverticular disease.

MEDICATIONS
Protonix 40 mg daily, Avandia 4 mg daily.

Allergies
None known.


Allergies
None known.

Physical Exam
Physical exam revealed a frail-appearing elderly man. Vital signs: Pulse 70, regular. Blood pressure 140/82. Temperature 96.7. Skin: No Pallor. HEENT: No scleral icterus. Neck: Without goiter. No carotid bruits. Lungs clear. Heart: Systolic ejection murmur. Abdomen distended. Positive fluid wave. No masses. Rectal was negative.

LABORATORY
Hemoglobin 13, hematocrit 39.2, WBC 8.1, platelets 330,000. Chemistry: Sodium 133, potassium 4.6, cholride 98, CO2 30, glucose 102, BUN 22, Creatinin3e 81.1. Ascitic fluid: Albumin was 2.5, cell count was 677, protein was 4.1, CEA was 2.5. PSA was 2.77. Alpha-fetoprotein was 2.3. Urine culture was negative. Ascitic fluid culture were negative, CA-1919 was 58.

The ideology of the Patient sisidies was not totally clear it was felt that the patient was to debilitated to be a candidate for chemotherapy the patient did undergo a MRCP, which did not show evidence of a definite pancreatic mass

The patient did undergo a proper ultrasound of the hepatic veins which showed no eveidence of hypatic vein thrombosis
The patient did receive thyroid replacement and he was started also on megas, the family made preparations for the patient to go home with hospice home care a definitive diagnosis had not been made though the CAT scan had been highly suspicious of parineal carsinomatosis.

What quiz # ?