Age: 61.0
Sex: F
Vaccine: COVID19
Symptoms: Procedural pain, Protein urine present, Red blood cell count decreased, Red blood cells urine, Red cell distribution width normal
Clinical narrative: Document Type: Internal Medicine IP Consultation   Document Subject: Consult Note   Performed By: MD on October 10, 2024 15:42 EDT   Verified By: MD on October 10, 2024 15:42 EDT   Encounter Info: Hospital, Inpatient, 10/10/24 -     * Final Report *            Referral Source  None, None      Subjective     This note was dictated using Dictation. If any errors with dictation, please contact me via diagnotes for clarification.     Primary service: General Surgery  Reason for consult: Medical comanagement  Referral source Dr.      Chief complaint: Admission for bowel resection, adenocarcinoma of descending colon     This is a 64-year-old female with a past medical history of hypertension, CKD stage III, recently diagnosed colon cancer, COPD, anxiety, normocytic anemia who presents to Hospital on 10/10/2024 for a scheduled bowel resection.  Hospitalist service consulted postoperatively for assistance with COPD management.  She appears to be on 5 L nasal cannula.  Vital signs otherwise stable.  Leukocytosis noted on labs this morning with a WBC of 10,700.  H&H appears to be stable and around her baseline.  CKD stage III appears to be stable.  Urinalysis negative.  Recent chest x-ray on 10/1/2024 showed mild left basilar atelectasis but no other acute findings.  She did have an outpatient pulmonology consultation prior to surgery and recommendation was to have her under ICU care after extubation as well as to make sure that she was extubated after being fully awake.     Patient seen and examined.  Has appropriate postoperative abd pain pain.  Reports baseline 2LNC. No CP. No SOB. Reports she chronically has wheezing, some days are worse than others. Has no other complaints.  All questions answered at the bedside.  Review of Systems     per HPI???????  Physical Exam/Objective  Vitals & Measurements last 24 hours  T: 36.4 °C (Axillary)  TMIN: 36.2 °C (Temporal Artery)  TMAX: 37.3 °C (Temporal Artery)  BP: 135/68  HR: 76 (Monitored)  HR: 76 (Peripheral)  RR: 18  SpO2: 97%  Oxygen Therapy: Nasal Cannula Humidified  Oxygen Flow Rate: 5 (L/min)  FiO2: 0.4  WT: 74.00 kg (WFC)  BMI: 26.3   Hemodynamics   Neurologic   Patient Weight  Current Daily Weight:    74 kg    10/10/24  BMI:    26.3    10/10/24    Overweight (BMI 25-29.9) Patient Height  Current Height:    167.6 cm    10/10/24     Vent Settings - Last Documented  ETCO2                         0              10/10/24 11:15:00  Oxygen Therapy                Nasal Cannula H10/10/24 14:19:00  FIO2, Vital Signs             0.4            10/10/24 12:27:00     I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 10/09 - 10/10  Total Intake 0.00 mL    Total Output 0.00 mL     Balance 0.00 mL     Lines, Tubes, and Drains  IV cannula Forearm Right 18 gauge   PIV     IV cannula Hand Left 20 gauge   PIV     Urethral Indwelling/Continuous 16 Fr   Catheter     Code Status  Resuscitation Status - Ordered    -- 10/10/24 11:50:00 EDT, Full Code     Constitutional:  No acute distress Eyes:  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender Respiratory:  On 5LNC, wheezing bilaterally, nonlabored, symmetric chest wall expansion Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, appropriately tender post-op, abd binder in place Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Warm, dry Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect???????   Assessment/Plan      1. Colon adenocarcinoma   C18.9    2. S/P colon resection   Z90.49  Problems 1-2:  Management per general surgery  S/p resection 10/10/24  Colon biopsy in August 2024 showed adenocarcinoma involving fragments of tubulovillous adenoma with high-grade dysplasia.  Monitor H&H post-op   3. Normocytic anemia   D64.9  The patient presents with anemia chronic and normocytic due to chronic kidney disease& IDA at present is stable.  Continue to trend serial analysis as appropriate with nutritional or blood product supplementation as required.   4. Chronic obstructive lung disease (disorder)   J44.9  Chronic, stable, continue routine management and RT protocol   5. Chronic kidney disease, stage 3   N18.30  Chronic, stable, monitor   6. Chronic hypoxemic respiratory failure (disorder)   J96.11  Chronic, stable, continue routine management and RT protocol  Baseline 2LNC -- > currently on 5LNC post-op and we will wean as tolerated???????   7. Hypertension   I10  Will titrate regimen accordingly???????   8. Anxiety   F41.9  Chronic, stable, continue routine management and RT protocol   DVT ppx: per primary  Code: FULL   Dispo:   Per surgery. Hospitalist will continue to follow.   ???????   Orders:   albuterol, 1 Puff, Inhalation, Aerosol, MDI/DPI Inhaler Treatment, Q6H, PRN, Wheezing, 10/10/24 15:30:00 EDT  fluticasone-vilanterol, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, Daily, 10/11/24 9:00:00 EDT  Sodium Chloride 0.9% 1000 mL, Total Volume (mL) = 1,000, IV Continuous, 10/10/24 11:50:00 EDT, 100 mL/hr, Clinical Weight  umeclidinium, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, Daily, 10/11/24 9:00:00 EDT  End Tidal CO2 Monitor Continuous  Initiate Respiratory Protocol    Chronic Problem List    Anemia  Anxiety  Chronic hypoxemic respiratory failure (disorder)  Chronic kidney disease, stage 3  Chronic obstructive lung disease (disorder)  Hypertension  Mammogram declined  Osteoporosis screening declined  Positive colorectal cancer screening using Cologuard test  Procedure/Surgical History  ?Colonoscopy (07/29/2024)   Surgical History Internal  10/10/2024    Colonoscopy Submucosal Injection     MD  07/29/2024    Colonoscopy Bx    MD  Medications  Home Medications (9) Active  DME (Vendor) Nebulizer See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  ferrous gluconate 324 mg (38 mg elemental iron) oral tablet 324 mg = 1 Tablet, Orally, TID  hydrOXYzine pamoate 25 mg oral capsule   hydrOXYzine pamoate 25 mg oral capsule 25 mg = 1 Capsule, PRN, Orally, 4 Times Daily  levalbuterol CFC free 45 mCg/inh inhalation aerosol 1 Puff, PRN, Inhalation, Q6H  losartan 25 mg oral tablet 50 mg = 2 Tablet, Orally, Daily  Trelegy Ellipta 100 mCg-62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily, J44.9  Vitamin D3 50 mCg (2,000 intl units) oral capsule 50 mCg = 1 Capsule, Orally, Daily  Active Scheduled Inpatient Medications  fluticasone-vilanterol (fluticasone-vilanterol 100 mCg-25 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 10/11/24 09:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q12H, Start: 10/10/24 21:00:00  Zosyn, Injection, 3.375 GM, IVPB, Q8H, Indication: Intra-Abdominal Infection, Start: 10/10/24 12:00:00  umeclidinium (umeclidinium 62.5 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 10/11/24 09:00:00  Sodium Chloride 0.9% 1,000 mL IV Continuous 100 mL/hr       One-Time Medications Given 10/09/24 00:00:00 TO 10/10/24 15:41:41  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, ONCE, (1 DOSE 10/10/24 07:24:00)  metroNIDAZOLE, Infusion, 500 mg, IVPB, ONCE, (1 DOSE 10/10/24 07:23:00)  PRN Medications (0600 - 0559) from 10/09 - 10/10  acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, 1 Puff, Inhalation, Q6H, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, Q4H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q4H, 0  Dose(s)   promethazine, 6.25 mg, IVPB, Q6H, 0  Dose(s)   Allergies   NKA  No Known Medication Allergies  Social History    Alcohol   Current, 1-2 times per year   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Unemployed, Work/School description: Housekeeper; hasn't worked since early 1990s.   Home/Environment   Lives with Spouse. Feels unsafe at home: No.   Substance Abuse   Marijuana, Daily   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. 1.5 packs per day. Started age 15.0 Years. Stopped age 59 Years.  Family History   Pulmonary embolism: Mother.   Father: History is negative  Deceased Family Member(s)  Relationship: Mother, Age: Unknown, Cause: Pulmonary embolism  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.7 k/cumm High (10/10/24 07:08:00)  RBC: 3.88 million/cumm (10/10/24 07:08:00)  Hgb: 11.3 GM/dL Low (10/10/24 07:08:00)  Hct: 34.2 % Low (10/10/24 07:08:00)  MCV: 88 fL (10/10/24 07:08:00)  MCH: 29.3 pg (10/10/24 07:08:00)  MCHC: 33.1 GM/dL (10/10/24 07:08:00)  RDW: 14.3 % (10/10/24 07:08:00)  Platelet: 394 k/cumm (10/10/24 07:08:00)  MPV: 7.5 fL (10/10/24 07:08:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (10/10/24 07:08:00)  Potassium SerPl QN: 3.6 mmol/L (10/10/24 07:08:00)  Chloride SerPl QN: 102 mmol/L (10/10/24 07:08:00)  Carbon Dioxide SerPl QN: 27 mmol/L (10/10/24 07:08:00)  Anion Gap: 10 mmol/L (10/10/24 07:08:00)  BUN SerPl QN: 17 mg/dL (10/10/24 07:08:00)  Creatinine SerPl QN: 1.15 mg/dL (10/10/24 07:08:00)  Estimated GFR (CKD-EPI, no race): 53 mL/min/1.73m2 Low (10/10/24 07:08:00)  Estimated CRCL (CG): 51 mL/min Low (10/10/24 07:08:00)  Glucose SerPl QN: 106 mg/dL High (10/10/24 07:08:00)  Calcium Total SerPl QN: 9.7 mg/dL (10/10/24 07:08:00)  Urine Studies:  Color: Light-Yellow (10/10/24 09:02:00)  Clarity: Clear (10/10/24 09:02:00)  Specific Gravity: 1.011 (10/10/24 09:02:00)  pH: 5.5 (10/10/24 09:02:00)  Protein: 30 Abnormal (10/10/24 09:02:00)  Glucose: Normal (10/10/24 09:02:00)  Ketones: NEGATIVE (10/10/24 09:02:00)  Bilirubin: NEGATIVE (10/10/24 09:02:00)  Hgb Ur: NEGATIVE (10/10/24 09:02:00)  Nitrite: NEGATIVE (10/10/24 09:02:00)  Urobilinogen: Normal (10/10/24 09:02:00)  Leukocyte Esterase Ur: NEGATIVE (10/10/24 09:02:00)  WBC: 0-5 (10/10/24 09:02:00)  RBC: 0-2 (10/10/24 09:02:00)  Bacteria: NONE (10/10/24 09:02:00)  Squamous Epithelial: Few (10/10/24 09:02:00)  Hyaline Casts: >20 (10/10/24 09:02:00)  All Other Labs:  ABO Rh: A Pos (10/10/24 07:08:00)  IAT Interp: Pos (10/10/24 07:08:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.          Signature Line Electronically Signed on 10/10/24 15:42 EDT ________________________________________________________ MD