• ED Course:
    • Diagnostically:
      • Interpretation of Pulse Oximetry:
        • No evidence of hypoxia on pulse oximetry in emergency department
      • Laboratory Results Reviewed. Analysis/Interpretation:
        • Pregnancy Test
          • negative
        • Basic Labs:
            • CBC:
            • No significant luekocytosis/neutropenia, no unexpected anemia, no thrombocytopenia.
            • Mild leukocytosis suggestive of infectious process
            • BMP:
            • No significant pathologic electrolyte derangements.
          • Basic laboratory analyses does not suggest more pathologic process in patient at this time.
          • _
        • Complete Laboratory Analysis:
            • CBC:
            • No luekocytosis, no unexpected anemia, no thrombocytopenia.
            • Mild luekocytosis suggestive of infectious process.
            • _
            • BMP:
            • No significant pathologic electrolyte derangements.
            • LFTs/lipase:
            • No laboratory evidence of hepato-biliiary pathology.
            • UA:
              • No consistent with urinary tract infection
                • in conjunction with clinical context
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          • _
      • EKG Interpretation:
        • Normal EKG (Indication: eval for ischemia):
            • EKG: NSR, regular rate, normal axis, normal intervals, no abnormal TWI, no ST elevation/depression.
          • Interpretation: No clear evidence of active ischemia on EKG
        • Normal EKG (Eval for arrhythmia/syncope):
            • EKG: Normal Sinus Rhythm. No arrythmia (no PACs, no PVCs), no brugada wave, no prolonged QTc, no delta wave/no shortened PR, no episilon wave, no evidence of ischemia.
          • Interpretation: No cardiogenic etiology for syncope obvious on EKG.
        • Sinus tachycardia, no abnormal TWI, no significant ST elevation/depression
        • Non-specific repolarization abnormalities. No ST elevation/depression.
        • Evidence of previous or active myocardial ischemia by abnormal TWI. NSR.
        • Evidence of previous myocardial ischemia by pathologic Q waves.
        • ST elevation concerning for active myocardial ischemia/infarct.
        • _
      • Radiograph Interpretation:
        • CXR
          • Normal CXR. Trachea midline. No plueral effusions. No air under diagphrams. No parenchymal radio-opacities thereby less likely pneumonia or pulmonary edema. Lung markings throughout – no radiographic evidence of pneumothorax.
          • Cardiomegaly. Otherwise non-remarkable CXR. Trachea midline. No plueral effusions. No air under diagphrams. No parenchymal radio-opacities thereby less likely pneumonia or pulmonary edema.. Lung markings throughout – no radiographic evidence of pneumothorax.
          • Pulmonary edema. Evidenced radio-opacities consistent with fluid in pulmonary parachyma.
          • Pneumonia. Evidenced by consolidation concerning for pneumonia.
          • Non-specific diffuse opacities. Concerning for diffuse infectious process verses pulmonary edema.
          • Not indicated. Given patient is not comorbid, not other extremes of age, there are no abnormal vital signs-specifically no tachycardia, no tachypnea, no fever, and the pulmonary exam is unremarkable, bacterial pneumonia is sufficiently unlikely that a chest radiograph is not indicated at this time. Patient was advised to return precautions in case of subsequent development of superimposed bacterial infection.
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