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Emergency Department Report Emergency Room

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Emergency Department Report Emergency Room
An Emergency Department Report dated 12/02/2016, stated that the claimant was admitted due to hyperglycemia. He also presented with a dry cough, a pain rated at 7/10, generalized weakness, and polydipsia. His laboratory test revealed a blood glucose level was 861, BUN of 30 (high), creatinine of 1.50, EGFR of 40 (low), sodium of 129 (low), chloride of 92 (low), and a carbon dioxide of 18 (low). His respiratory rate was 13 breaths per minute. His chest x-ray revealed a normal result. He was diagnosed with hyperglycemia, fatigue, raised serum creatinine, and chest pain. He was instructed to monitor blood sugar. The plan of care included a BMP, Nitroglycerin paste, Aspirin, cardiology evaluation, urology evaluation, and continued use of Albuterol. He was discharged in stable condition. …show more content…

He was seen by Infectious Disease, Pulmonary, Cardiology, Endocrinology, and Psychiatry. It was noted that the claimant's breathing has been slowly improved over the hospital course. The CT scan of the chest revealed a 1-cm nodular opacity at the left lower lobe. There were fibrotic changes, significant calcification of the NAD, and a multi-nodular thyroid. The thyroid ultrasound revealed heterogenous masses. An uptake scan was recommended. Moreover, his 2D-echo revealed a normal LV size and function with an ejection fraction of 60%. An aortic valve sclerosis and a dilated left atrial cavity were noted. A follow-up visit with the specialist doctors was recommended. He was discharged in stable condition on

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