Jun 21st, 2015
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Adams State College
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SORIANO, NENITA DEOUILLA75 FEMALEADMITTED September 21, 2014 8:15 pmDIAGNOSIS: CVD Ischemic vs. hemorrhagic probably at cerebellar area to consider Aspiration pneumonia; astheniaACTIVE PROBLEMSCVD ischemic vs. hemorrhagic Aspiration pneumoniaAsthenia anemiaDIAGNOSTIC RESULTSSputum Gram StainFew gram positive cocci in singles, in pairs, in short chains and in small clusters with occasional Gram negative cocci in pairs and occasional gram negative bacilliFew fungal elements (spores and hyphae) were also seen many epithelial cells and many pus cells notedOccasional (< 1 per lpfFew (1-9 /lpf)Moderate (10 -25 /lpf)Many (>25 / lpf)ABGMetabolic acidosis fully compensated with severe hypoxemiaPH: 7.396PaCO2: 32.4Hco3: 19.5CBCHypochromicWBC: 11.8CT SCANIschemic change, left external capsule and cerebellumCerebro cerebellar atrophyCEREBELLAR INFARCT RIGHT CHEST XRAYPneumonia both lower lobesSignificant clearing Subsequent atelectasis and or fibroticsLeft lower lung lobet/a cardiomegallyCHEST APPneumonia both lobesAtherosclerotic aortic knobECGIrregular rateLeft ventricular hypertrophyWith PACsLVH by voltageInferolateral wall ischemiaCBG Capillary blood 271 (74 -106 fasting; 74- 140 nonfasting)Urea Nitrogen 37.90 high (8-23 mg/dl)Creatinine high 3.15 (0.50 0.90 mg/dl)ION SELECTIVE ELECTRODEIonized Calcium 1.13 (1.15- 1.33 mmol/ l)URINE Protein positiveGlucose positiveSpecific gravity 1. 025Pus : 1-2 hpfRBC 0-2

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