The claimant was admitted on 12/02/2016 due to shortness of breath and COPD.
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
12/13/2016.
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The Laboratory Report dated 12/02/2016 revealed glucose of 583 (high), BUN of 29 (high), creatinine of 1.62 (high), neutrophil of 72.6 (high), sodium of 131 (low), chloride of 94 (low), anion gap of 13 (high), and AST of 11 (low).
The Consultation Report dated 12/05/2016, indicated that the claimant complained of shortness of breath, persistent cough, and pleuritic chest pain. He appeared lethargic and weak. His blood pressure was 130/70 mmHg and his blood glucose level was 189. The Microbiology Report revealed a growing pseudomonas aeruginosa. The chest x-ray revealed a negative result. IV Cefepime Albuterol, and CT scan were suggested.