Age: 53.0
Sex: M
Vaccine: COVID19
Symptoms: Blood bilirubin normal, Blood calcium decreased, Blood chloride normal, Blood creatinine increased, Blood fibrinogen
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By:  DO on December 08, 2022 06:56    Verified By:  DO on December 08, 2022 06:56   Encounter Info: Hospital, Inpatient, 12/07/22 -     * Final Report *        Chief Complaint   ams  History of Present Illness/Subjective     53-year-old male with past medical history of stroke with residual right-sided weakness and aphasia, atrial fibrillation, coronary artery disease, COPD, hypothyroidism, CKD, diabetes, hypertension hyperlipidemia presenting with altered mental status.  Patient was noted at his assisted living facility to be more fatigued than normal.  Family at bedside states that he is normally able to take pills himself but today was not able to stay awake long enough to take his own medications.  When staff checked his vital signs they found him to have low blood pressure and oxygen saturation prompting them to send him into the emergency department today.  Family notes that he has had cough and congestion recently.  No other complaints per family.  No fever, chest pain, abdominal pain, vomiting diarrhea or constipation.  No recent travel or sick contacts.  No recent trauma.  Patient is aphasic and unable to answer questions.   Patient was started on levophed in the ED. CT chest abd pelv revealed colitis. INR is supratherapeutic but no signs of active bleeding.  This patient is critically ill due to metabolic, hemodynamic and/or respiratory instability. They require high complexity evaluation, decision making, and care. They require ICU level of care and monitoring due to high risk of clinical decompensation with high risk of morbidity and mortality. Critical care time includes, but is not limited to, bedside assessment, review of medical record, radiographic and laboratory results, ventilator and/or respiratory management, review of ekg and/or cardiac monitoring, critical decision making, coordination of care with consultants and/or care team, and documentation of critical intervention/plans, and consultation with patient and/or family. Time excludes any procedural time.  I spent greater than 75 minutes in the evaluation and management of this patient with more than 50% of the time spent counseling and/or coordinating care.  I counseled the patient and/or family about the findings, differential diagnoses, my assessment, recommendations, and plan.  I coordinated care with the multidisciplinary healthcare team.  Review of Systems     patient is aphasic and unable to answer questions therefore unable to complete ros.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.1 (36.4-37.1)  Temp (FAHR) 98.8 (97.5-98.8), BP 109/53 (96-149)/(51-66), HR 83 (76-89), RR 13 (0-19), O2Sat 97 (92-97) Neurologic (most recent and range for last 24 hours)  GCS 13(13-13)     Patient Weight  Current Daily Weight:    165.3 kg    12/08/22  Previous Daily Weight:    165 kg    12/07/22  Difference from Previous:    0.300 kg  BMI:    44.3    12/07/22    Morbid Obesity (BMI > = 40) Patient Height  Current Height:    193 cm    12/08/22        General: Fatigued appearing but arousable to verbal stimuli  Head: Normocephalic, atraumatic.  Eyes: No acute pupillary or ocular movement abnormalities. Sclera are non-icteric and conjunctiva are pink bilaterally.  ENT: Oropharynx clear and without edema, injection nor exudate. The uvula is midline. There is no appreciable cervical lymphadenopathy. The neck is supple with full range of motion.  Respiratory: No respiratory distress. +coarse breath sounds b/l  CV: Regular rate and rhythm. No murmur, gallop or rub.  Abdomen: Soft, supple and non-distended. No tenderness to palpation. There is not any organomegaly, nor are any masses appreciated.  Neuro: Moving LUE and LLE, not moving RUE or RLE; baseline per family  Skin: Normal color. Warm and dry.  Musculoskeletal/Extremities: No swollen or painful joints. No obvious deformities.  3+ pitting edema RLE  Psych: Aphasic  Assessment/Plan      1. Septic shock     maintain map > 65, patient is currently weaning down on levophed  received sepsis bolus will cont ivf  sepsis likely 2/2 colitis vs pneumonia vs other  obtain procalcitonin, follow pan cultures  legionella, urine strep ag, viral panel neg   2. Colitis    cont broad spectrum abx with vanc/cefepime/flagyl  npo for now, will consider GI vs surgical consults on routine basis as lactate is improving  bowel ischemia on ct is likely 2/2 colitis if ischemia does exist is likely 2/2 hypovolemic shock rather than stenosis vs acute thrombosis given patient's inr is >10 and he is not having significant abd pain  cont to monitor   3. Respiratory failure with hypercapnia     cont bipap, serial blood gases, resp assessment  svns as appropriate   4. Anemia     5. On warfarin for atrial fibrillation      6. Supratherapeutic INR    initial hg 8.3 but given no signs of active bleeding with INR>10 will hold warfarin and trend INR, however if patient develops worsening anemia, will utilize transfusion to maintain hg >7 as well as provide IV vitamin k at that point  cont rate control as needed and as bp will allow, if patient develops rvr while hypotensive, will begin digoxin   7. Acute on chronic renal failure     ckd component likely due to dm, long standing htn, and microvascular disease,  aki is likely prerenal and is improving with volume resuscitation though patient is likelt to go into atn so will need tele and monitoring of electrolytes repleting as needed, unclear what baseline crcl is  nephrology eval prn   8. Hyperglycemia      9. Diabetes     accuchecks with iss q4h while npo   10. Hypomagnesemia     replete and cont to monitor   11. Hemiplegia of right nondominant side due to infarction of brain      12. CVA, old, aphasia      13. Multiple comorbid conditions     Noted, contin to monitor and when able to, resume home meds   Orders:   acetaminophen, 650 mg, Rectally, Tablet, Q4H, PRN, Pain, Mild PO (1-3 out of 10)/Fever, 12/07/22 23:38:00  cefePIME, 1 GM, IVPB, Injection, Q8H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), 12/08/22 0:00:00, 12.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 50  Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 12/07/22 23:38:00, PRN - See Comments, Clinical Weight  Dextrose 5% in Water 500 mL, Total Volume (mL) = 500, IV, 12/08/22 1:15:00, Other - See Comments, Clinical Weight  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 12/07/22 23:38:00   glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 12/07/22 23:38:00   insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 12/07/22 23:38:00   magnesium sulfate, 4 GM, IVPB, Infusion, Q12H, PRN, Lab (Details Required), 12/07/22 23:40:00, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  magnesium sulfate, 2 GM, IVPB, Infusion, Q12H, PRN, Lab (Details Required), 12/07/22 23:40:00, 25 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 50  metroNIDAZOLE, 500 mg, IVPB, Infusion, Q8H, 12/08/22 8:00:00, 100 mL/hr, Infuse Over 60 minutes, Total Volume (mL) = 100  NORepinephrine 8 mg + Sodium Chloride 0.9% 250 mL, Total Volume (mL) = 250, IV, 12/07/22 23:39:00, Titrate - See Comments  phytonadione, 5 mg, IVPB, Injection, ONCE, 12/08/22 7:00:00 EST, 12/08/22 7:00:00, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  potassium chloride, 20 mEq, IVPB, Infusion, Unscheduled, PRN, Lab (Details Required), 12/07/22 23:40:00, 50 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 100  potassium chloride, 20 mEq, IVPB, Infusion, Unscheduled, PRN, Lab (Details Required), 12/07/22 23:40:00, 50 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 100  potassium chloride, 20 mEq, IVPB, Infusion, Unscheduled, PRN, Lab (Details Required), 12/07/22 23:40:00, 50 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 100  Sodium Chloride 0.9% 250 mL, Total Volume (mL) = 250, IV, 12/08/22 1:15:00, Other - See Comments, Clinical Weight  Sodium Chloride 0.9% 500 mL, Total Volume (mL) = 500, IV, 12/08/22 1:15:00, Other - See Comments, Clinical Weight  sodium phosphate, 28 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 12/07/22 23:40:00, 37.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 150  sodium phosphate, 21 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 12/07/22 23:40:00, 50 mL/hr, Infuse Over 3 Hours, Total Volume (mL) = 150  sodium phosphate, 21 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 12/07/22 23:40:00, 50 mL/hr, Infuse Over 3 Hours, Total Volume (mL) = 150  pharmacy dosing consult, Consult, Miscellaneous, Daily, 12/08/22 9:00:00   ABO and Rh  Admit to Inpatient  Aspiration Precautions  Auto Diff  Auto Diff  BIPAP Intermittent  Blood Gas Venous QN  Call (Specify)  Call (Specify)  Call Blood Glucose  Call Blood Glucose  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mean Arterial Pressure  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  Call Urine Output  CBC w/Differential  CBC w/Differential  CBC w/Differential   Pharmacy Dosing Consult  Collect Specimen  Collect Specimen  Collect Specimen  Comp Metabolic Panel  Comp Metabolic Panel  Continuous Oxygen Saturation   Alert and Sepsis Screen  Do Not (Specify)  Document per Nursing (Specify)  Dysphagia Screen by RN  Fall Precautions  Fibrinogen  Fluid Intake Requirement  Gluc-Strip POC  Glucose POC  Hgb A1C HPLC Bld QN  Indirect Antiglobulin Test  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  L pneumophila Ag Ur QL  LDH SerPl QN  Level of Care  Magnesium SerPl QN  Magnesium SerPl QN  Maintain (Specify)  Medical Service  Medication Message to Nursing  Message to Nursing  Message to Nursing  Message to Nursing  Message to Nursing  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Notify Provider  NPO Advance as Tolerated  Packed Red Blood Cells Leukoreduced CMV Safe  Peripheral IV Insertion  Peripheral IV Insertion  Phosphorus SerPl QN  Phosphorus SerPl QN  Procalcitonin  Procalcitonin  PTINR  Reason for Not Ordering Long-acting Insulin  Reason for Not Ordering Medication Prophylaxis  Resp CX + Stn  Resuscitation Status  Sequential Compression Device  Strep pneumoniae Ag Urine  Telemetry Class III 24hr Recommendation  Troponin-I High Sensitivity  TSH w FreeT4 reflex  UA Microscopic  Urinalysis w Culture Rflx  Urinary Catheter Insertion  Urinary Catheter to Dependent Drainage  Vancomycin Pharmacy Dosing Consult  Vancomycin   Vital Signs  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 12/07/22 23:38:00, Full Code   Chronic Problem List    Aphasia  Atrial fibrillation, persistent  CAD (coronary artery disease)  Cardiomyopathy  COPD mixed type  Depression  Diabetic neuropathy, type II diabetes mellitus  Dysphagia  Gastric reflux  Gastrostomy present  Generalized OA  Hallux abductovalgus with bunions  Hemiplegia of right nondominant side due to infarction of brain  Hyperlipemia, mixed  Hypertension  Hypothyroid  Insulin long-term use  Low vitamin D level  Moderate major depression  Monoclonal gammopathy  Morbid obesity  Onychogryphosis  Onychomycosis  OSA on CPAP  Osteoarthritis  Persistent insomnia  Pre-ulcerative calluses  Pulmonary fibrosis  Schizophrenia  Stage 3 chronic kidney disease  Tobacco use  Typical atrial flutter  Uncontrolled type 2 diabetes mellitus with hyperglycemia  Procedure/Surgical History  ?Afib/Aflutter ablation ?Cholecystectomy ?colonoscopy - 2013 normal ?Kidney stone   Surgical History Internal  12/28/2021    Gastrostomy Tube Chg Wo Scope  MD  02/02/2021    Tracheostomy    MD  01/28/2021    EGD W Perc Gastrostomy Tube Place/Remova    MD  Medications   Home Medications (20) Active  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  albuterol HFA MDI 90mCg/puff inhalation aerosol 360 mCg = 4 Puff, PRN, Inhalation, Q2H  amLODIPine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  Azithromycin 5 Day Dose Pack 250 mg oral tablet Take 2 tablets day 1, then 1 tablet days 2 to 5, Orally, Daily  baclofen 10 mg oral tablet 10 mg = 1 Tablet, Orally, TID  carvedilol 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, BID  gabapentin 300 mg oral capsule 300 mg = 1 Capsule, Orally, QHS  glucagon 1 mg/0.2 mL subcutaneous solution 1 mg, Subcutaneous, ONCE, may repeat once in 15 minutes  glucose 15 g/42 mL oral gel See Instructions, If BS is below 60, administer 15mg. May repeat in 15 minutes if needed  insulin glargine 100 units/mL subcutaneous solution 12 Units, Subcutaneous, BID  insulin lispro 100 Units/mL injection See Instructions, Per sliding scale:BS<60 call MD, follow hypoglycemia protocol251-300=4301-350=6351-400=8401-450=10451-500=12BS>500, 14 units and call MD  levothyroxine 25 mCg (0.025 mg) oral tablet 25 mCg = 1 Tablet, Orally, QAM  losartan 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily  olanzapine 10 mg oral tablet 20 mg = 2 Tablet, Orally, Daily  omeprazole 20 mg oral delayed release tablet 20 mg = 1 Tablet, Orally, Daily  Vitamin D3 1250 mCg (50,000 intl units) oral capsule 1,250 mCg = 1 Capsule, Orally, Every Friday  warfarin 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Zoloft 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  cefePIME, Injection, 1 GM, IVPB, Q8H, Indication: Pneumonia - CAP (MRSA/PSA Risk Factors), Start: 12/08/22 00:00:00  metroNIDAZOLE, Infusion, 500 mg, IVPB, Q8H, Start: 12/08/22 08:00:00  vitamin K, Injection, 5 mg, IVPB, ONCE, Start: 12/08/22 07:00:00  pharmacy dosing consult, Miscellaneous, Vancomycin , Consult, Daily, Start: 12/08/22 09:00:00  Dextrose 10% in Water PREMIX  500 mL IV  PRN - See Comments     NORepinephrine PREMIX + Sodium Chloride 0.9% PREMIX IV Titrate - See Comments 0 mCg/min  12/08/22  Sodium Chloride 0.9%  500 mL IV  Other - See Comments     Dextrose 5% in Water  500 mL IV  Other - See Comments     Sodium Chloride 0.9%  250 mL IV  Other - See Comments       One-Time Medications Given 12/07/22 00:00:00 TO 12/08/22 06:55:21  None Reported  PRN Medications (0600 - 0559) from 12/07 - 12/08  acetaminophen, 650 mg, Rectally, Q4H, 0  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   magnesium sulfate, 2 GM, IVPB, Q12H, 0  Dose(s)   magnesium sulfate, 4 GM, IVPB, Q12H, 0  Dose(s)   potassium chloride, 20 mEq, IVPB, Unscheduled, 0  Dose(s)   sodium phosphate, 21 mmol, IVPB, Unscheduled, 0  Dose(s)   sodium phosphate, 28 mmol, IVPB, Unscheduled, 0  Dose(s)   Allergies   NKA  No Known Medication Allergies  Social History    Alcohol   Past   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Unemployed   Home/Environment   Lives with Mother.   Substance Abuse   Past, Marijuana, 1-2 times per month   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Family history is negative  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 16.8 k/cumm High (12/08/22 04:34:00)  RBC: 2.84 million/cumm Low (12/08/22 04:34:00)  Hgb: 7.1 GM/dL Low (12/08/22 04:34:00)  Hct: 23.1 % Low (12/08/22 04:34:00)  MCV: 81 fL (12/08/22 04:34:00)  MCH: 25 pg Low (12/08/22 04:34:00)  MCHC: 30.8 GM/dL Low (12/08/22 04:34:00)  RDW: 16.8 % High (12/08/22 04:34:00)  Platelet: 288 k/cumm (12/08/22 04:34:00)  MPV: 8.9 fL (12/08/22 04:34:00)  Neutrophils %: 80 % (12/08/22 04:34:00)  Lymphocytes %: 9 % (12/08/22 04:34:00)  Monocytes %: 8 % (12/08/22 04:34:00)  Eosinophils %: 3 % (12/08/22 04:34:00)  Basophils %: 0 % (12/08/22 04:34:00)  Absolute Neutrophil: 13.4 k/cumm High (12/08/22 04:34:00)  Absolute Lymphocyte: 1.6 k/cumm (12/08/22 04:34:00)  Absolute Monocyte: 1.3 k/cumm (12/08/22 04:34:00)  Absolute Eosinophil: 0.5 k/cumm High (12/08/22 04:34:00)  Absolute Basophil: 0.1 k/cumm (12/08/22 04:34:00)  Chemistry:  Sodium SerPl QN: 140 mmol/L (12/08/22 04:34:00)  Potassium SerPl QN: 4.2 mmol/L (12/08/22 04:34:00)  Chloride SerPl QN: 100 mmol/L (12/08/22 04:34:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (12/08/22 04:34:00)  Anion Gap: 10 mmol/L (12/08/22 04:34:00)  BUN SerPl QN: 36 mg/dL High (12/08/22 04:34:00)  Creatinine SerPl QN: 2.73 mg/dL High (12/08/22 04:34:00)  Estimated GFR (CKD-EPI, no race): 27 mL/min/1.73m2 Low (12/08/22 04:34:00)  Estimated CRCL (CG): 52 mL/min Low (12/08/22 04:34:00)  Glucose SerPl QN: 134 mg/dL High (12/08/22 04:34:00)  Calcium Total SerPl QN: 7.9 mg/dL Low (12/08/22 04:34:00)  Phosphorus SerPl QN: 4.9 mg/dL (12/08/22 04:34:00)  Alkaline Phos SerPl QN: 92 Units/L (12/08/22 04:34:00)  ALT SerPl QN: 10 Units/L (12/08/22 04:34:00)  AST SerPl QN: 7 Units/L Low (12/08/22 04:34:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (12/08/22 04:34:00)  Total Protein SerPl QN: 5.2 GM/dL Low (12/08/22 04:34:00)  Albumin SerPl QN: 2.5 GM/dL Low (12/08/22 04:34:00)  Magnesium SerPl QN: 1.4 mg/dL Low (12/08/22 04:34:00)  Lipase SerPl QN: 3 Units/L Low (12/07/22 14:48:00)  Troponin-I High Sensitivity: 7 ng/L (12/08/22 00:33:00)  BNP Pl QN: 14 pg/mL (12/07/22 14:48:00)  Lactate Venous Pl QN: 1.7 mmol/L (12/07/22 16:43:52)  pH Bld Venous QN: 7.32 Low (12/08/22 04:34:00)  PCO2 Bld Venous QN: 56 mmHg (12/08/22 04:34:00)  PO2 Bld Venous QN: 47 mmHg High (12/08/22 04:34:00)  Base Excess Bld Venous: 2 mmol/L (12/08/22 04:34:00)  Bicarb Bld Venous Calc: 29 mmol/L (12/08/22 04:34:00)  O2 Sat Bld Venous Calc: 79 % (12/08/22 04:34:00)  Patient Temperature: 37 DegC (12/08/22 04:34:00)  TSH 3rd Gen SerPl QN: 3.26 mcU/mL (12/08/22 00:33:00)  Coagulation:  PT: >140.0 High (12/08/22 00:33:00)  INR: >10.17 Critical (12/08/22 00:33:00)  Urine Studies:  Color: Yellow (12/08/22 04:59:00)  Clarity: Clear (12/08/22 04:59:00)  Specific Gravity: 1.025 (12/08/22 04:59:00)  pH: 5.0 (12/08/22 04:59:00)  Protein: 30 Abnormal (12/08/22 04:59:00)  Glucose: NEGATIVE (12/08/22 04:59:00)  Ketones: TRACE. Abnormal (12/08/22 04:59:00)  Bilirubin: SC Small Abnormal (12/08/22 04:59:00)  Hgb Ur: LARGE. Abnormal (12/08/22 04:59:00)  Nitrite: NEGATIVE (12/08/22 04:59:00)  Urobilinogen: 1.0. (12/08/22 04:59:00)  Leukocyte Esterase Ur: NEGATIVE (12/08/22 04:59:00)  WBC: 0-5 (12/08/22 04:59:00)  RBC: 6-10 Abnormal (12/08/22 04:59:00)  Bacteria: Moderate Abnormal (12/08/22 04:59:00)  Squamous Epithelial: Few (12/08/22 04:59:00)  Hyaline Casts: 0-2 (12/08/22 04:59:00)  Triple Phosphate Crystals: PRESENT. (12/08/22 04:59:00)  Amorphous Crys Ur: PRESENT. (12/08/22 04:59:00)  Toxicology:  Vancomycin Ran SerPl QN: 13.4 mCg/mL (12/08/22 04:34:00)  All Other Labs:  ABO Rh: O Pos (12/08/22 02:32:00)  IAT Interp: Pos (12/08/22 02:32:00)  Antibody ID: Anti-LeA (12/08/22 02:32:00)  COVID 19 Specimen Source: Nasopharyngeal (12/07/22 14:10:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (12/07/22 14:10:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/07/22 14:57:00)  Rapid Influenza A PCR: Not Detected (12/07/22 14:57:00)  Rapid Influenza B PCR: Not Detected (12/07/22 14:57:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/07/2022 16:07 - XR Chest PA or AP Portable  IMPRESSION:1.  Cardiomegaly with low lung volumes. Question mild pulmonaryvascular congestion versus crowding due to hypoinflation.2.  No definite focal infiltrate.Thank you for consulting our team of subspecialty radiologists at the Radiology facility. Healthcare providers wishing to discussthis case further can contact the Cardiothoracic Reading Room at the phone number. For after-hours or emergency department cases, pleasecall phone number.    12/07/2022 17:08 - CT Head W/o IV Contrast  IMPRESSION:1. Findings suggestive of nonacute ischemic change involving the leftbasal ganglia and left corona radiata, grossly unchanged from theprior study.2. No definite evidence of acute intracranial hemorrhage, new foci ofparenchymal edema, significant intracranial mass effect or depressedcalvarial fracture.Thank you for consulting our team of subspecialty radiologists at the Radiology facility. Healthcare providers wishing to discussthis case further can contact the Neuroradiology Reading Room at the phone number. For after-hours or emergency department cases, pleasecall phone number.    12/07/2022 17:15 - CT Chest Abd and Pelvis W/o IV Contrast  IMPRESSION:CHEST 1.  Right-sided trace pleural fluid and lower lobe atelectasis. 2.  Right-sided endobronchial secretions or mucus plugging. Recommendclinical correlation for reactive airway disease or aspiration.ABDOMEN/PELVIS 1.  Post right lower quadrant and bowel wall marked inflammation.Please correlate clinically for mesenteric and bowel ischemia. Alsoconsider infectious or inflammatory bowel disease.2.  Peripancreatic inflammation versus motion artifact. Pleasecorrelate clinically for acute pancreatitis.3.  Right-sided free fluid.4.  Cholecystectomy.5.  Hepatic steatosis.6.  Bilateral nonobstructive renal calculi.7.  Left adrenal stable myolipoma.NOTE: Result communication and receipt documented in the facility Results Reporting System.Thank you for consulting our team of subspecialty radiologists at the Radiology facility. Healthcare providers wishing to discussthis case further can contact the Abdominal Imaging Reading Room at the phone number. For after-hours or emergency department cases, pleasecall phone number.                Signature Line Electronically Signed on 12/08/22 06:56  ________________________________________________________