Patient name: Smith, Mike
Second Floor - South
zA d m i s s i o n P r o f i l e
Scaned Admission Profile
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Nursing Assessment
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Hematology
WBC RBC HGB HCT MCV MCH MCHC RDW
x10 3 x10 6 g/dl % fl pg g/dl %
Ref 4.8 4.70 14.0 42.0 80.0 27.0 32.0 11.5
Range: 10.8 6.10 18.0 52.0 94.0 31.0 36.0 15.5
------- ------ ------ ------ ------- ---- ---- ----
02/24/99 1330 9.3 5.03 15.3 47.0 93.5 30.4 32.5 14.0
MPV PLT * NEUT LYMPH MONO EOS BASO
x10 3 * % % % % %
Ref 7.4 130 * 43.0 20.5 5.5 .9 .2
Range: 10.4 400 * 65.0 45.5 11.7 2.9 1.0
---- ---- * ---- ---- ---- ---- ----
02/24/99 1330 7.7 201 92.5 H 3.7 L 3.0 L .3 L .5
NEUT LYMPH MONO EOS BASO
# # # # #
Ref 2.2 1.2 .3 .0 .0
Range: 4.8 2.9 .8 .2 .1
---- ---- ---- ---- ----
02/24/99 1330 8.7 H .3 L .3 .0 .0
MANUAL BAND SEG LYMPH MONO EOS BASO META MYELO NUCLEATED RBC
DIFF: % % % % % % % % /100 wbc
REF: 0 45 15 2 0 0
RANGE: 8 75 45 10 5 3
---- ----- ----- ---- --- ---- ---- ----- -------
02/24/99 1330 14 H 80 H 4 L 2
Chemistry
NA K+ CL- CO2 GLUCOSE UREA CREAT
mmol/l mmol/l mmol/l mmol/l mg/dl mg/dl mg/dl
EF 137 3.6 98 22 75 9 .8
RANGE 145 5.0 107 30 110 20 1.5
----- ----- ----- ---- ----- ----- ------
02/24/99 1330 132 L 3.7 97 L 22 228 H 25 H 1.8 H
02/26/99@0549 144 H
CA PROT ALB TBIL AST ALKPHOS
mg/dl g/dl g/dl mg/dl iu/l iu/l
REF 8.4 6.3 3.5 .2 17 38
RANGE 10.2 8.2 5.0 1.3 59 126
---- ---- ---- ---- ----- -----
02/24/99 1330 8.9 6.6 3.5 .8 28 67
Microbiology
===========================================================================
....SPUTUM CULTURE
02/24/99 1017 SPECIMEN #: 8977 RECEIVED: 02/24/99 :
SOURCE: SPUTUM SETUP: 02/24/99 1100
....PRELIMINARY REPORT
NORMAL FLORA
02/26/99
...CULTURE, ROUTINE Date Reported
FINAL REPORT
Isol# 1 2+ YEAST
02/27/99
Isol# 2 4+ NORMAL FLORA
Respiratory Therapy
...NEBULIZER TREATMENT ORDERS
02/24/99@1016 Routine ARTERIAL BLOOD GAS 118407 238703 _ STAT
---------------------------------------------------------------------------
...OXYGEN ORDERS
02/24/99@1020 Routine OXYGEN 118414 238712 2__ LPM NASAL C
---------------------------------------------------------------------------
...IPPB ORDERS
02/24/99 1016 Routine EKG 118409 238706
02/24/99 1017 Routine SPUTUM COLLECT/INDUCTION 118412 238710
--------------------------------------------------------------------------
...RESP NOTES 1
02/28/99 0827 1 OXYGEN IN USE: CANNULA @ 2 LPM
X ALERT X AWAKE X COOPERATIVE
COMMENTS: TX GIVEN IN HIGH FOWLERS
NO ADVERSE REACTIONS NOTED
HEART RATE: HR BEFORE: 72 HR DURING: 78 HR AFTER: 80
RESPIRATORY RATE: RR BEFORE: 16 RR DURING: 16 RR AFTER: 16
PROCEDURE EXPLAINED TO PATIENT, ALL QUESTIONS ANSWERED.
...RESP NOTES 1
02/28/99 0827 DIMINISHED BILAT.
BREATH SOUNDS ARE SLIGHTLY IMPROVED AFTER THERAPY.
NON PRODUCTIVE COUGH
RESPIRATORY CARE NOTES
02/28/99 1336 DATE: 2/28/99 TIME: 1108 B. STRAUB CRTT,RCS
THERAPY DURATION: 12 MIN VIA MOUTHPIECE
1 SVN w/ UD ALBUTEROL, 2cc 20% MUCOMYST
...RESP NOTES 1
02/28/99 1336 X ALERT X AWAKE X COOPERATIVE
COMMENTS: PT HAD O2 TURNED OFF HE STATED HE WAS GOING HOME
NO ADVERSE REACTIONS NOTED
HEART RATE: HR BEFORE: 76 HR DURING: 80 HR AFTER: 80
RESPIRATORY RATE: RR BEFORE: 20 RR DURING: 20 RR AFTER: 20
PROCEDURE EXPLAINED TO PATIENT, ALL QUESTIONS ANSWERED.
...NEBULIZER TREATMENT RECORD
02/24/99@1017 Routine HAND HELD NEBULIZER TX 118413 238711 _ UNIT DOSE VE
...RESP NOTES 1
02/28/99 1336 DIMINISHED BILAT.
BREATH SOUNDS ARE SLIGHTLY IMPROVED AFTER THERAPY.
PRODUCTIVE COUGH
AMOUNT: SM CONSISTENCY: THIN COLOR: CLEAR
ECG Readings
03/02/99 1220 Routine Abnormal ECG Normal Sinus Rhytmh with 1st degree AV block. Left Ventricular Hypertrophy with repolarization abnormality.
click on image to enlarge
Dietary
...MENU ORDERS
02/24/99@1022 Routine LOW CHOLESTEROL, LOW FAT 118415 238713 LOW__GM SODIUM
Routine SODIUM RESTRIC/OTHER (S) 118416 238714 LOW__GM SODIUM
02/24/99 1025 Routine STEP1CARDIAC-2GMNA LOWCH 118417 238715
02/25/99 1419 Routine REGULAR DIET 119316 240732
NUTRITIONAL ASSESSMENT
S:
08/16/99 1655 CURRENT DIET IS ADEQUATE AND APPROPRIATE TEST
NUTRITIONAL
ASSESSMENT UBW IBW ADMIT UBW IBW
SEX/HT. WT. % %
_______ ___ ___ _____ ____ ___
08/16/99 1655 M 170 180 170 175 5 5
Adjusted Weight: 172 lbs
...MENU ORDERS
08/18/99 1339 Routine REGULAR DIET 122567 247952
Revised Result / See Amended
...RPR
!5/24/99 2237R REACTIVE
Anatomic Pathology
GROSS DESCRIPTION ...................................................
Labeled "Gallbladder"
Received is a gallbladder measuring 6.0 x 3.0 x2.5 cm. Opening
the gallbladder reveals a _________, _____ mucosa with _________
No discrete gallstones are found. A representative portion of
Gallbladder wall is submitted.
MICROSCOPIC DESCRIPTION ...................................................
(micro)
SIGN-OFF ...................................................
Radiology
View abdominal series: Flat (Supine) view
View abdominal series: Upright view
View AP chest:
The radiographs were interpreted as showing non-specific findings. Because the cause of the abdominal pain was suspected to be constipation, the patient was given an enema. Following this, he passed a large amount of stool and felt much better. His abdominal exam continued to be benign. He was discharged from the ED. Overnight, the patient continued to experience fever at home and some abdominal pain though the degree of abdominal pain was improved. A review of his radiographs the following morning revealed an alternative diagnosis for his symptoms.
Review his abdominal series again above.
If you are still unable to identify the radiographic diagnosis, review the focused enlarged view of the lesion.
This view provides a focused view of the lesion. Note the triangular density superimposed on the heart. The flat (supine) view shows this best (see below). It is located at the very top of the flat (supine view).
This represents a pulmonary infiltrate in the medial aspect of the left lower lobe. The top of it is cut off in the flat (supine) view of the abdomen. It is almost impossible to appreciate this density on the upright view because most of it is cut off. The chest radiograph was taken using a different degree of penetration to view the lungs better. Because of this, it is even more difficult to appreciate the infiltrate behind the heart. Upon close inspection, you should be able to appreciate the triangular density superimposed on the heart on the chest radiograph view. A lateral view of the chest was not taken in this case since the chest view was part of an abdominal series that was ordered.
The patient was placed on antibiotics and his fever promptly improved by the next day. His abdominal pain and his other symptoms gradually improved.
Discussion and Teaching Points:
Pneumonia is a known cause of abdominal pain. This diagnosis is often not considered because the abdominal pain is the chief complaint. The pain can be very severe at times. This can easily mislead a clinician to limit the area of investigation to the abdomen. This pitfall should be avoided. Causes of abdominal pain that are not related to the abdomen include pneumonia, pneumothorax, pneumomediastinum, pericarditis, zoster, vertebral conditions (eg., osteomyelitis, discitis), diabetic ketoacidosis, etc. Adult conditions that are less likely but still possible in children include myocardial ischemia and aortic dissection.
Pulmonary conditions should be considered in patients with respiratory symptoms, tachypnea, or a borderline oxygen saturation. Documentation of these findings should be routine in patients with abdominal pain. The history should include the presence of and the severity of respiratory symptoms. The vital signs should include a respiratory rate and a pulse oximetry reading. The examination should include notes describing the presence or absence of any observed tachypnea, the degree of coughing observed, the characteristics of the cough (eg., moist, productive, bronchospastic, dry, etc.), and the standard pulmonary auscultation and percussion findings. If any of these findings suggest the possibility of pneumonia, PA and lateral chest radiographs should be ordered, or alternatively, treatment prescribed for a clinical diagnosis of a respiratory infection.
Although the likelihood of aortic dissection is low (especially in children), this condition is associated with a substantial likelihood of death which may be preventable if the diagnosis is suspected early. While aortic contrast studies by CT or aortography are not routine, one suggestion has been to document the presence and character of peripheral pulses in all patients presenting with abdominal pain.
Although the appendix is often the focus of clinical examination in patients with abdominal pain, there are other serious causes of abdominal pain that should be considered as well, such as intussusception, volvulus, pancreatitis, ovarian torsion, testicular torsion, acute cholecystitis, etc.
The radiographic findings in intussusception may range from normal to various indirect signs of intussusception (refer to Case 2 which describes the radiographic findings in intussusception). A volvulus is usually associated with a true bowel obstruction, but the presentation clinically and radiographically can occasionally be subtle.
Ovarian torsion may be a difficult diagnosis to make. Even the use of color flow doppler ultrasound used to assess blood flow to the ovaries is not able to totally rule out this diagnosis since, early in its presentation, some blood flow may still be preserved.
Testicular torsion is usually suspected on clinical grounds, but occasionally the testes are not examined in some patients because their pants and underwear (or diapers) are not removed. Younger patients may fail to point to their testes as the location of the pain. Some may complain of non-specific abdominal pain because of failure to appreciate the source of the pain, or because of modesty.
In summary, the causes of abdominal pain are extensive. In the acute care setting, it is most important to rule out diagnoses that must be made early to result in the best possible outcome for the patient. Some of these diagnoses have been mentioned, but there are others.
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