C10031857 / invoice 10000

Reason: R/v - Condition WorseningAppointment Notes: increased respiratory signsHistory:Here on Tuesday - gastro signs - that has resolved but developed respiratory signs over last 24hrs - hiding this morning under house which is unusual for her. Still eating, no vomiting since gastro episodes. Breathing sounds normal for her but this is far more laboured. O is away - mother looking after her - she will be back in bris at 2pm today. Hx of cancer? Not sure where. Examine:Breathing - increased resp effort in chest with some abdominal effort as wellCan hear crackles present in all lung fieldsDifficult to hear heart clearly amongst chest sounds > HR approx 130bpm from what can hear, no obvious murmur and none mentioned previouslyMm purple/pink tinged, CRT <2 secsTracheal palp WNLStertor normal for her in pastTemp 37.9Suggested imaging:Lateral and V/D images taken - stressed during imaging and turned more purple > required O2 by maskCranial lung fields not clear, opacity present in all views, reduced visualisation of cardiac silhouette - possible nodular changes around hilar region. Given IV 0.6mls frusemide - did improve breathing slightlyPlan:Discussed with O mother > feel needs supportive care to get through until O arrives home to make further decisions - oxygen therapy neededDiscussed possibility of neoplasia, vs. Cardiac, vs. Other - could do repeat images after diuretic to see if any fluid cleared, or attempt thoracic ultrasound. O may consider euth.    Vital Signs    Weight: 10.1;