Age: 74.0
Sex: F
Vaccine: COVID19
Symptoms: Urine ketone body absent, Urine leukocyte esterase positive, Urobilinogen urine, White blood cell count increased, pH urine normal
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: NP on May 23, 2023 13:21 EDT   Verified By: NP on May 23, 2023 13:21 EDT   Encounter Info: Hospital, Emergency, 05/23/23 - 05/23/23    * Final Report *        Basic Information  Time Seen:  NP / 05/23/2023 11:14  Chief Complaint  Abdominal Pain  History of Present Illness     A 75-year-old female  with a hx of COPD, htn presents with abdominal pain on and off since yesterday evening epigastric going down into the bilateral R much greater than left, lower quadrants with associated decreased appetite and some nausea.  Denies any fevers or chills denies vomiting denies diarrhea.  She states she had a small normal soft stool this morning.  Review of Systems      Constitutional:  no fever, no chills, no sweats, no weakness Respiratory:  no shortness of breath, no cough Cardiovascular:  no chest pain Additional ROS info:  Except as noted in the above Review of Systems and in the History of Present Illness, all other systems have been reviewed and are negative or noncontributory.  Physical Exam/Objective  Vitals & Measurements most recent  T: 37.3 °C (Oral)  BP: 151/63  HR: 80 (Monitored)  RR: 18  SpO2: 93%  Oxygen Therapy: Room air  Oxygen Flow Rate: 2 (L/min)  WT: 79.50 kg (WFC)  HT: 162.1 cm       General:  alert, no acute distress Cardiovascular:  regular rate and rhythm, normal peripheral perfusion Respiratory:  Lungs CTA, respirations non-labored ABD abdomen large amount of soft bowel sounds x4 quadrants.  mild Tender to palpation left lower quadrant mid lower quadrant and Significant tenderness to right lower quadrant.  Rebound tenderness on the right lower quadrant.  No guarding. Extremities:  no deformity, no trauma Neurological:  oriented x4, LOC appropriate for age  Medical Decision Making     triage note reviewed  history by patient  NPO  1245 spoke with Dr. regarding results of CT  1304docunotes Dr. for admission  1310 Dr. at the bedside spoke with patient for laparoscopic appendectomy  1315 Zosyn ordered, not given in the ED due to surgical team taking her to the OR now  1320 left the ED via gurney for the OR          Re-Assessment  pain controlled  Condition     stable  Assessment/Plan     Admit, surgery this afternoon   1. Acute appendicitis   K35.80    2. Hypokalemia   E87.6    3. Leukocytosis   D72.829    Orders:   Sodium Chloride 0.9% 1,000 mL, Total Volume (mL) = 1,000, IV, 05/23/23 12:54:00 EDT, 100 mL/hr, Clinical Weight  Bed Request (Decision to Admit)  CT Abd/Pelvis W/IV Contrast     Follow Up  No qualifying data available   Chronic Problem List    Colon cancer screening  COPD (chronic obstructive pulmonary disease)  Hyperglycemia  Hyperlipidemia  Hypertension  Leg pain, bilateral  Long term use of drug  Low back pain  Mixed stress and urge urinary incontinence  Osteoarthritis  Osteopenia  Seasonal allergies  Procedure/Surgical History  ?Diabetic retinal eye exam (09/15/2021) ?Diabetic retinal eye exam (03/16/2021) ?Cholecystectomy ?Lumpectomy ?TL - Tubal ligation    Medications  Home Medications (11) Active albuterol-ipratropium inh soln 2.5 mg-0.5 mg/3 mL 3 mL, PRN, Inhalation, 4 Times Daily Citracal + D 2 Tablet, Orally, Daily Daliresp 500 mCg oral tablet 500 mCg = 1 Tablet, Orally, Daily Incruse Ellipta 62.5 mCg inhalation powder 62.5 mCg = 1 Each, Inhalation, Q24H, doses should be taken at least 24 hours apart losartan-hydroCHLOROthiazide 100mg-12.5mg oral tablet 1 Tablet, Orally, Daily losartan-hydroCHLOROthiazide 100mg-12.5mg oral tablet 1 Tablet, Orally, Daily magnesium gluconate 250 mg oral tablet 250 mg = 1 Tablet, Orally, BID Misc Supplies See Instructions, Portable Oxygen ConcentratorDx:  Moderate oxygen dependent COPDRA sat 76% with activity on 2.5 lpm Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily Trelegy Ellipta 200 mCg-62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q6H  Medication Administration   Given  HYDROmorphone Inj ED (1 mg/mL), 0.5 mg, IV Push  ondansetron, 4 mg, IV Push  Sodium Chloride 0.9% - ED Bolus, 500 mL, IVPB  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Married, 2 Children   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Leukemia: Brother.  Lung cancer..: Mother.  Pancreatic cancer: Brother.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  05/23/23 10:47  11.3  High  02/13/23  6.6          RBC  05/23/23 10:47  4.40  02/13/23  4.60          Hgb  05/23/23 10:47  12.7  02/13/23  13.5          Hct  05/23/23 10:47  38.6  02/13/23  40.2          MCV  05/23/23 10:47  88  02/13/23  87          MCH  05/23/23 10:47  28.9  02/13/23  29.3          MCHC  05/23/23 10:47  32.9  02/13/23  33.5          RDW  05/23/23 10:47  14.7  High  02/13/23  14.3          Platelet  05/23/23 10:47  217  02/13/23  273          MPV  05/23/23 10:47  7.5  02/13/23  8.3          Neutrophils %  05/23/23 10:47  86  02/13/23  74          Lymphocytes %  05/23/23 10:47  8  02/13/23  18          Monocytes %  05/23/23 10:47  5  02/13/23  7          Eosinophils %  05/23/23 10:47  0  02/13/23  1          Basophils %  05/23/23 10:47  0  02/13/23  0          Absolute Neutrophil  05/23/23 10:47  9.8  High  02/13/23  4.9          Absolute Lymphocyte  05/23/23 10:47  0.9  Low  02/13/23  1.2          Absolute Monocyte  05/23/23 10:47  0.5  02/13/23  0.5          Absolute Eosinophil  05/23/23 10:47  0.0  02/13/23  0.1          Absolute Basophil  05/23/23 10:47  0.1  02/13/23  0.0           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  05/23/23 10:47  133  Low  02/13/23  131  Low          Potassium SerPl QN  05/23/23 10:47  3.3  Low  02/13/23  3.7          Chloride SerPl QN  05/23/23 10:47  93  Low  02/13/23  92  Low          Carbon Dioxide SerPl QN  05/23/23 10:47  32  High  02/13/23  30  High          Anion Gap  05/23/23 10:47  8  02/13/23  9          BUN SerPl QN  05/23/23 10:47  9  02/13/23  12          Creatinine SerPl QN  05/23/23 10:47  0.62  02/13/23  0.66          Estimated GFR (CKD-EPI, no race)  05/23/23 10:47  >90  02/13/23  >90          Estimated CRCL (CG)  05/23/23 10:47  80  02/13/23  75          Glucose SerPl QN  05/23/23 10:47  134  High  02/13/23  112  High          Calcium Total SerPl QN  05/23/23 10:47  10.3  02/13/23  9.6          Alkaline Phos SerPl QN  05/23/23 10:47  77  02/13/23  74          ALT SerPl QN  05/23/23 10:47  11  02/13/23  41          AST SerPl QN  05/23/23 10:47  17  02/13/23  31          Bilirubin Total SerPl QN  05/23/23 10:47  0.6  02/13/23  0.4          Total Protein SerPl QN  05/23/23 10:47  8.5  High  02/13/23  8.7  High          Albumin SerPl QN  05/23/23 10:47  4.6  02/13/23  4.6          Lipase SerPl QN  05/23/23 10:47  17              Lactate Venous Pl QN  05/23/23 10:47  0.8  02/13/23  1.0           Urinalysis FS  LATEST RESULTS  HISTORICAL RESULTS          Color  05/23/23 11:41  Light-Yellow  02/13/23  Yellow          Clarity  05/23/23 11:41  Clear  02/13/23  Clear          Specific Gravity  05/23/23 11:41  1.017  02/13/23  1.015          pH  05/23/23 11:41  8.0  02/13/23  6.5          Protein  05/23/23 11:41  Negative  02/13/23  Negative          Glucose  05/23/23 11:41  Normal  02/13/23  Negative          Ketones  05/23/23 11:41  Negative  02/13/23  Negative          Bilirubin  05/23/23 11:41  Negative  02/13/23  Negative          Hgb Ur  05/23/23 11:41  Negative  02/13/23  Negative          Nitrite  05/23/23 11:41  Negative  02/13/23  Negative          Urobilinogen  05/23/23 11:41  Normal  02/13/23  Normal          Leukocyte Esterase Ur  05/23/23 11:41  Negative  02/13/23  Trace Abnormal      Diagnostic Results  CT Abd/Pelvis W/IV Contrast    05/23/23 12:27:16  IMPRESSION:   Status post cholecystectomy.   Colonic diverticulosis without evidence of acute diverticulitis.   Thickened, inflamed appendix with appendicoliths consistent with  acute, uncomplicated appendicitis.     Electronically Signed by:     Signed By:  MD     ************************************************** XR Chest PA or AP Portable    05/23/23 11:07:22  IMPRESSION:   Coarse lung markings, similar to 2/13/2023.   No focal infiltrates or other acute findings.   Electronically Signed by:     Signed By: MD        Signature Line Electronically Signed on 05/23/23 13:21 EDT ________________________________________________________ NP