Vu, Thuy Phi MS (80 YEARS, FEMALE) Allergies- seafood, beef Clinician: I…lob, Cristopher (General Surgical)Marketing Research and Data Analysis
Presenting Complaint IMSA Admission (Yiu, Garg #917) 80yo F presenting with worsening dyspnoea
History of Presenting Com… Patient reviewed with daughter by the bedside Daughter reported that patient had prawn, egg and rice for dinner yesterday Following dinner, paticnt started to cough and experience SOB Daughter had to speak to nurse to administer her puffers Informed daughter of thc CT chest report findings and that patient has a potential underlying lung malignancy Informed that in order to definitively diagnose cancer, patient will require a biopsy of the mass Informed given her advanced age and frailty, there is a possibility that oncology team may not recommend further treatment and may consider treating her palliatively Systems Review Daughter deni. any loss of weight in the past few months Daughter denies any cough Hx of severe dementia Denies any significant pain at the current moment ObsNitals BP 138/102, RR 19, 02 sats 99% on RA, HR 100, afebrile Examination Looks okay lying down on bed Alert but confused and disorientated PEARL HSDNM Chest clear left, reduced AE on the right Abdo SNT Calves SNT, nil peripheral oedema
Laboratory WCC 11.8, Neutrophils 11:8 GGT 86, ALP 255, Albumin 23 CRP 89 Met_ti.U_E-11 _gna