Age: 81.0
Sex: F
Vaccine: COVID19
Symptoms: Urine ketone body present, Urine leukocyte esterase, Urobilinogen urine, Uterine leiomyoma, Uterine mass
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: MD on May 29, 2023 14:16   Encounter Info: Hospital, Emergency, 05/29/23 - 05/29/23    * Preliminary Report *        Basic Information  Time Seen: MD / 05/29/2023 14:05  Chief Complaint  Altered Mental Status  History of Present Illness     Patient is an 82 year old female presenting today due to altered mental status. Pt was found by her daughter today somewhat confused on the couch. She was noted to be covered in feces. Daughter reports a similar instance in the past during which the pt had a UTI. Daughter had not seen the pt for the past 2 days.  No known nausea, vomiting, fevers, or cough.  Review of Systems      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: 36.8 °C (Oral)  BP: 188/79  HR: 104 (Peripheral)  RR: 18  SpO2: 95%  Oxygen Therapy: Room air  WT: 77.90 kg (WFC)  HT: 152 cm       General:  alert, mild distress, covered in feces on arrival. Head: Atraumatic, normocephalic Eyes: PERRLA. EOMI  Neck: Trachea midline. Normal ROM Cardiovascular:  regular rate and rhythm, normal peripheral perfusion Respiratory:  Lungs CTA, respirations non-labored Musculoskeletal:  no deformity, no trauma Skin: Warm, dry Neurological:  oriented x3, LOC appropriate for age, no focal motor or sensory deficits.  Medical Decision Making     The patient is a 82 year old female who presented today for evaluation of -     History is obtained from -    pt and daughter   Factors adding to complexity: Chronic pain syndrome, age, chronic opioid use  External record review: Primary care notes from earlier this year   Pertinent exam: Pt arrived covered in feces form shoulder down to legs.   Differentials include but are not limited to: UTI, PNA, Electrolyte derangement, rhabdomyolysis  Imaging/Labs/initial treatment ordered: CBC, CMP, Lactate, Cultures, Abx due to her presentation of being covered in feces. CT head.   EKG was personally interpreted by me with the following findings:  Performed at 1422,  Rate 99 bpm: Sinus rhythm no obvious ST abnormalities.  Normal intervals.   Updates:  Labs were reviewed which had an elevated white count at 17.7.  Lactic acid was normal.  UA had some red blood cells.  Chest x-ray unremarkable.  CT scan of head and CT scan of abdomen currently pending.  She was given antibiotics earlier due to the concern for infection and as she was covered in feces on arrival.  CK was mildly elevated at 273.  05/29/23 21:42:33  Consult: Case discussed with Dr., hospitalist who accepts admission.    ---------    I reviewed nursing documentation as well as all vital signs, and any EKGs, laboratory results, and imaging results if done pertaining to this ER visit. I personally discussed the results with the patient as well. All questions were answered. The patient was understanding of the workup/results and agreeable with the plan.     Condition     Stable  Disposition: 05/29/23 21:42:14 Admit, accepted by Dr           Follow Up  No qualifying data available   Chronic Problem List    Anxiety  B12 deficiency  Chronic pain  Chronic, continuous use of opioids  Diabetic retinopathy not detected  Edema  Encounter for long-term (current) use of medications  Hyperlipidemia  Hypothyroidism  Medicare annual wellness visit, subsequent  Needs flu shot  Neoplasm of uncertain behavior of skin  Osteoarthritis  Senile osteoporosis  Type 2 diabetes mellitus  Procedure/Surgical History  ?Diabetic retinal eye exam (09/16/2022) ?Diabetic retinal eye exam (09/14/2021) ?Eye examination (08/08/2018) ?Basal Cell Carcinoma removed from Face ?Tonsillectomy with adenoidectomy ?Tubal ligation    Medications  Home Medications (12) Active Accu-Chek Aviva Plus Test Strips Check daily, Other, Unscheduled, ACCU CHECK test strips dx code Check once daily E11.9 aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily cyanocobalamin 1000 mCg sublingual tablet 1,000 mCg = 1 Tablet, Sublingually, Daily Fish Oil 1000 mg oral capsule 1,000 mg, Orally, Daily glipiZIDE 2.5 mg oral tablet, extended release 2.5 mg = 1 Tablet, Orally, Daily, with breakfast levothyroxine 125 mCg (0.125 mg) oral tablet 125 mCg = 1 Tablet, Orally, Daily Norco 7.5 mg-325 mg oral tablet 1 Tablet, Orally, BID, Fill when due: June 2023 Norco 7.5 mg-325 mg oral tablet 1 Tablet, Orally, BID, Fill when due: May 2023 Norco 7.5 mg-325 mg oral tablet 1 Tablet, Orally, BID, Fill when due: April 2023 oxyBUTYnin 5 mg/24 hours oral tablet, extended release 5 mg = 1 Tablet, Orally, Daily simvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime vitamin D (ergocalciferol) , Orally, 2000 mg daily  Medication Administration   Given  piperacillin-tazobactam, 4.5 GM, IV Push. For: Sepsis (Update Indication in 36-48 hrs)  Sodium Chloride 0.9% - ED Bolus, 1000 mL, IVPB  vancomycin, IVPB. For: Sepsis (Update Indication in 36-48 hrs)  Allergies   povidone iodine topical (critical)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   single, 5 children, 1 deceased - retired   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. Started age 20.0 Years. Stopped age 75 Years.  Family History   HTN (hypertension)...: Mother and Father.  Hyperlipidemia: Mother.  Lung cancer: Father.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  05/29/23 14:26  17.7  High  07/24/22  9.8          RBC  05/29/23 14:26  5.43  High  07/24/22  4.95          Hgb  05/29/23 14:26  15.6  High  07/24/22  14.1          Hct  05/29/23 14:26  47.9  07/24/22  42.7          MCV  05/29/23 14:26  88  07/24/22  86          MCH  05/29/23 14:26  28.7  07/24/22  28.4          MCHC  05/29/23 14:26  32.5  07/24/22  32.9          RDW  05/29/23 14:26  15.7  High  07/24/22  15.3  High          Platelet  05/29/23 14:26  303  07/24/22  295          MPV  05/29/23 14:26  8.9  07/24/22  8.2          Neutrophils %  05/29/23 14:26  92  07/24/22  82          Lymphocytes %  05/29/23 14:26  3  07/24/22  8          Monocytes %  05/29/23 14:26  5  07/24/22  6          Eosinophils %  05/29/23 14:26  0  07/24/22  1          Basophils %  05/29/23 14:26  0  07/24/22  1          Absolute Neutrophil  05/29/23 14:26  16.2  High  07/24/22  8.1  High          Absolute Lymphocyte  05/29/23 14:26  0.6  Low  07/24/22  0.8  Low          Absolute Monocyte  05/29/23 14:26  0.9  07/24/22  0.6          Absolute Eosinophil  05/29/23 14:26  0.0  07/24/22  0.1          Absolute Basophil  05/29/23 14:26  0.1  07/24/22  0.1           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  05/29/23 15:42  140  07/24/22  142          Potassium SerPl QN  05/29/23 15:42  3.5  07/24/22  3.4  Low          Chloride SerPl QN  05/29/23 15:42  101  07/24/22  104          Carbon Dioxide SerPl QN  05/29/23 15:42  26  07/24/22  27          Anion Gap  05/29/23 15:42  13  High  07/24/22  11          BUN SerPl QN  05/29/23 15:42  19  07/24/22  19          Creatinine SerPl QN  05/29/23 15:42  0.81  07/24/22  0.86          Estimated GFR (CKD-EPI, no race)  05/29/23 15:42  72  07/24/22  68          Estimated CRCL (CG)  05/29/23 15:42  49  Low  07/24/22  47  Low          Glucose SerPl QN  05/29/23 15:42  118  High  07/24/22  106  High          Gluc-Strip, POC  05/29/23 14:22  114  High              Calcium Total SerPl QN  05/29/23 15:42  9.5  07/24/22  9.1          Alkaline Phos SerPl QN  05/29/23 15:42  59  07/24/22  46          ALT SerPl QN  05/29/23 15:42  10  07/24/22  16          AST SerPl QN  05/29/23 15:42  16  07/24/22  19          Bilirubin Total SerPl QN  05/29/23 15:42  0.9  07/24/22  0.5          Total Protein SerPl QN  05/29/23 15:42  7.7  07/24/22  7.2          Albumin SerPl QN  05/29/23 15:42  4.5  07/24/22  4.3          CK SerPl QN  05/29/23 15:42  273  High              Lactate Venous Pl QN  05/29/23 15:42  1.7               Urinalysis FS  LATEST RESULTS  HISTORICAL RESULTS          Color  05/29/23 14:26  Yellow  01/09/23  Yellow          Clarity  05/29/23 14:26  Clear  01/09/23  Clear          Specific Gravity  05/29/23 14:26  1.032  High  01/09/23  1.015          pH  05/29/23 14:26  5.5  01/09/23  6.5          Protein  05/29/23 14:26  100 Abnormal  01/09/23  Trace Abnormal          Glucose  05/29/23 14:26  Normal  01/09/23  Negative          Ketones  05/29/23 14:26  60 Abnormal  01/09/23  Negative          Bilirubin  05/29/23 14:26  Negative  01/09/23  Negative          Hgb Ur  05/29/23 14:26  Moderate Abnormal  01/09/23  Negative          Nitrite  05/29/23 14:26  Negative  01/09/23  Negative          Urobilinogen  05/29/23 14:26  Normal  01/09/23  Normal          Leukocyte Esterase Ur  05/29/23 14:26  Negative  01/09/23  Negative          WBC  05/29/23 14:26  6-10 Abnormal  01/09/23  0-5          RBC  05/29/23 14:26  21-50 Abnormal  01/09/23  None Seen          Bacteria  05/29/23 14:26  None  01/09/23  Trace          Squamous Epithelial  05/29/23 14:26  Few  01/09/23  Moderate          Mucous  05/29/23 14:26  Present  01/09/23  Present      Diagnostic Results  CT Abd/Pelvis W/O IV Contrast    05/29/23 19:05:42  IMPRESSION:  1. The study is degraded by patient motion. Examination was  performed without IV contrast.  2. A large (17 cm) cyst/cystic lesion in the right lower quadrant of  the abdomen extending into the right upper pelvis, favored to  represent mesenteric lymphatic malformation (mesenteric cyst). There  are no available prior CT scans for comparison. Other less likely  possibilities include right ovarian cystic neoplasm.  3. A 7 cm mass that appears to be arising from the uterine fundus,  favored to represent a subserosal fibroid.  4. Moderate sized hiatal hernia.  5. Nonobstructing right-sided nephrolithiasis.     Thank you for consulting our team of subspecialty radiologists. Please contact us with any questions.   Electronically Signed by:     Signed By: MD     ************************************************** CT Head W/o IV Contrast    05/29/23 19:47:50  IMPRESSION:  1. No acute intracranial abnormality.  2. Chronic findings as detailed.     Thank you for consulting our team of subspecialty radiologists. Please contact us with any questions.   Electronically Signed by:     Signed By: MD     ************************************************** XR Chest PA or AP Portable    05/29/23 15:18:37  IMPRESSION:  1. No acute findings in the chest.   Thank you for consulting our team of subspecialty radiologists. Please contact us with any questions.   Electronically Signed by:     Signed By: MD     ************************************************** XR Tibia/Fibula Right    05/29/23 19:08:22  impression.   IMPRESSION:  1. Negative for acute fractures or dislocations.  2. Mild circumferential soft tissue swelling about the distal calf  and ankle.  3. Negative for radiopaque foreign bodies.   Thank you for consulting our team of subspecialty radiologists. Please contact with any questions.   Electronically Signed by:     Signed By: MD