Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal pain lower, Acute kidney injury, Alanine aminotransferase normal, Anion gap, Anticoagulant therapy
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By, NP on February 03, 2023 17:48   Verified By: NP on February 03, 2023 17:48   Encounter Info: Hospital, Emergency, 02/03/23 - 02/03/23    * Final Report *  Document Contains Addenda          History of Present Illness/Subjective     Patient is a 77-year-old female with past medical history of myeloproliferative disorder, myelodysplastic syndrome, splenomegaly, anemia, arthritis, CKD, COPD, recurrent UTIs who presented to the emergency room with chief complaint of lower abdominal and back pain for the last several days at home additionally she has had fevers and chills.      Upon ER evaluation her temperature was 97.7, heart rate was 104, respiratory rate was 17 and room air sat was 95%.  Blood pressure was 103/66.  Lab work revealed a white blood cell count of 8.7, hemoglobin was 8.2, sodium was 134, GFR was 22, creatinine was 2.21.  Her baseline creatinine is around 1.1.  Troponin initially was 35 with repeat being 33 and her BNP was 101.  UA revealed evidence of UTI.  CT abdomen pelvis was completed showed continued splenomegaly, inflammation in the right renal pelvis may be artifact however can be seen in the setting of an a sending urinary tract infection.  No hydronephrosis.  Patient was started on IV antibiotics, ampicillin, gentamicin IV fluids and Tylenol.  She will be admitted for further evaluation management UTI, sepsis, pyelonephritis.     Patient is a full CODE STATUS.  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.6 (36.9-38.2)  Temp (FAHR) 99.7 (98.4-100.8), BP 115/52 (100-126)/(49-62), HR 83 (83-95), RR 19 (16-25), O2Sat 99 (86-99)     Patient Weight  Current Daily Weight:    63.6 kg    02/03/23    Patient Height  Current Height:    160 cm    02/03/23        Constitutional:   No acute distress ,   well-nourished Eyes:  PEERL,  EOMI,   normal conjunctiva ,   no scleral icterus ENMT:   Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB Cardiovascular:   Regular rate and rhythm Gastrointestinal:  Soft, mildly tender bilateral lower quadrant,  non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic:  Alert & Oriented x 3, no cognitive impairment ,   no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Sepsis   A41.9  Sepsis order set initiated We will continue with IV Zosyn as patient is allergic to Ceftin.  Previous micro on urine grew out E. coli pansensitive. Blood cultures are pending   2. Pyelonephritis   N12  Urine culture pending, IV antibiotics given in the ER we will continue with Zosyn   3. Urinary tract infection   N39.0  As above   4. Elevated troponin   R77.8  Chronic problems   Myelodysplastic syndrome/ Myeloproliferative disorder    -Under treatment per Dr.  splenomegaly As above this appears to be related to mixed bone marrow disorder both the dysplastic syndrome along with the myeloproliferative neoplasm.  Splenomegaly is more associated with myeloproliferative disorder. HLD  Resume home meds anxiety  Resume home meds   ???????Patient is full CODE STATUS.  DVT prophylaxis with Lovenox.   5. Acute kidney injury   N17.9  CKD stage III, give IV fluids normal saline at 100 mL an hour   Code Status   None Recorded   Chronic Problem List    Acute bronchitis  Anemia  Anxiety  Arthritis  Axillary lymphadenopathy  Body aches  Chronic back pain  CMC arthritis  CRF (chronic renal failure)  Diffuse cutaneous mastocytosis  Dysuria  Emphysema/COPD  Encounter for long-term (current) use of medications  Fatigue  Ganglion cyst of finger of left hand  H/O bone density study  Health care maintenance  Herniated disc, cervical  Hyperlipidemia  Hypertrophy of both inferior nasal turbinates  Hypoxemia  Insomnia  Left upper quadrant pain  Leg cramps  Leukocytosis  MDS (myelodysplastic syndrome)  Medicare annual wellness visit, subsequent  MGUS (monoclonal gammopathy of unknown significance)  Mucous cyst of finger  Needs flu shot  Nocturnal hypoxia  Osteoarthritis  Osteoarthritis of CMC joint of thumb  Osteoarthritis of finger of left hand  Osteoarthritis of finger of left hand  Osteoarthritis of right knee  Pain of right thumb  Pulmonary nodule seen on imaging study  Pyelonephritis  Refractory obstruction of nasal airway  Right knee pain  S/P total knee replacement  Sepsis  Situational depression  Skin rash  Spleen enlarged  Stomatitis  Systemic mastocytosis with associated clonal hematological non-mast cell lineage disease  Trigger finger of right hand  Trigger finger, right middle finger  Trigger finger, right ring finger  Urinary tract infection  UTI (urinary tract infection)  Procedure/Surgical History  melanoma removed from neck (12/05/2021) Knee replacement (04/01/2021) BACK SURGERY (01/10/2019) colonoscopy (12/13/2017) Rt LF- DIPJ Fusion, HWR OWW 6/6/2017 (No pkg) (06/06/2017) Rt Thumb CMCA w/FCR Tendon Trans, LF- DIPJ Fusion, Cyst Exc OWW 4/24/17 (04/24/2017) egd (03/13/2009) Appendectomy Cataract Cesarean section left nipple reconstruction Nasal surgery right breast biopsy Tonsillectomy and adenoidectomy Tubal ligation Varicose vein stripping   Surgical History Internal  04/01/2021    Knee Arthroplasty  (Right)    MD  01/10/2019    Spine Fusion Posterior Lumbar    MD  12/13/2017    Colonscpy Diagnostic/Screen     MD  Medications   Home Medications (19) Active  amoxicillin 500 mg oral tablet 2,000 mg = 4 Tablet, Orally, ONCE, 1 hour before dental procedure  Calcium 600+D oral tablet 1 Tablet, Orally, QHS  Colace 100 mg oral capsule 100 mg = 1 Capsule, Orally, QHS  CoQ10 300 mg oral capsule 300 mg = 1 Capsule, Orally, BID  cranberry oral capsule 1 Capsule, Orally, QAM  doxepin 25 mg oral capsule 50 mg = 2 Capsule, Orally, At Bedtime  EpiPen Auto Injector 0.3 mg, PRN, IM, ONCE  famotidine 20 mg oral tablet 20 mg = 1 Tablet, Orally, BID  fluocinolone 0.025% topical cream 1 App, Topical, BID  GaviLyte-G oral powder for reconstitution See Instructions, as directed.  hydroxyurea 500 mg oral capsule See Instructions, 1 Capsule Orally Daily Mon-Fri, 2 capsules on Sat & Sun  hydrOXYzine pamoate 25 mg oral capsule 25 mg = 1 Capsule, PRN, Orally, 4 Times Daily  levocetirizine 5 mg oral tablet 5 mg = 1 Tablet, Orally, BID  Lidocaine Viscous 2% mucous membrane solution See Instructions, PRN, Apply directly to mouth sore with cotton swab Q3-4H prn pain  Mobic 15 mg oral tablet 15 mg = 1 Tablet, Orally, Daily  montelukast 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Requip 0.25 mg oral tablet 0.25 mg = 1 Tablet, Orally, At Bedtime  tiZANidine 4 mg oral tablet 4 mg = 1 Tablet, Orally, Q8H  Tylenol Extra Strength 500 mg oral tablet 1,000 mg = 2 Tablet, PRN, Orally, Q6H  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 02/02/23 00:00:00 TO 02/03/23 17:48:03  acetaminophen, Tablet, 1,000 mg, Orally, ONCE, (1 DOSE 02/03/23 13:18:00)  ampicillin, Injection, 2 GM, IVPB, ONCE, (1 DOSE 02/03/23 14:29:00)  gentamicin, Injection, 280 mg, IVPB, ONCE, (1 DOSE 02/03/23 15:26:00)  ketoROLAC, Injection, 15 mg, IV Push, ONCE, (1 DOSE 02/03/23 11:49:00)  Lactated Ringers (LR - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 02/03/23 11:49:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 02/03/23 11:49:00)  PRN Medications (0600 - 0559) from 02/02 - 02/03  None Reported  Allergies   Ceftin (Rash)  sulfa drugs (Rash)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Home/Environment   married, 2 children - retired, Lives with Spouse.   Nutrition/Health   Diet: Regular. Caffeine intake amount: 2-3 cups coffee/day.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Arthritis: Mother.  CAD - Coronary artery disease: Father.  Coronary artery bypass graft: Father.  Depression: Mother.  Diabetes..: Mother.  Heart disease: Mother and Father.  Heart murmur: Mother.  Kidney stones: Son.  Liver cancer..: Father.  Osteoporosis...: Mother.  Stroke..: Mother.  Uterine cancer: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 8.7 k/cumm (02/03/23 11:48:00)  RBC: 2.86 million/cumm Low (02/03/23 11:48:00)  Hgb: 8.2 GM/dL Low (02/03/23 11:48:00)  Hct: 25.1 % Low (02/03/23 11:48:00)  MCV: 88 fL (02/03/23 11:48:00)  MCH: 28.6 pg (02/03/23 11:48:00)  MCHC: 32.6 GM/dL (02/03/23 11:48:00)  RDW: 33.4 % High (02/03/23 11:48:00)  Platelet: 50 k/cumm Low (02/03/23 11:48:00)  MPV: 10.3 fL (02/03/23 11:48:00)  # WBC Counted in Diff: 100 (02/03/23 11:48:00)  Band: 12 % (02/03/23 11:48:00)  Neutrophil: 68 % (02/03/23 11:48:00)  Lymphocyte: 17 % (02/03/23 11:48:00)  Monocyte: 3 % (02/03/23 11:48:00)  Number of Nucleated RBCs: 1 /100 WBC High (02/03/23 11:48:00)  Absolute Band: 1 k/cumm High (02/03/23 11:48:00)  Absolute Neutrophil: 5.9 k/cumm (02/03/23 11:48:00)  Abs Lymphocyte: 1.5 k/cumm (02/03/23 11:48:00)  Absolute Monocyte: 0.3 k/cumm (02/03/23 11:48:00)  RBC Morphology: See description UC (02/03/23 11:48:00)  Dacryocyte: Moderate (2+), (02/03/23 11:48:00)  Hypochromasia: Moderate (2+), (02/03/23 11:48:00)  Macrocyte: Moderate (2+), (02/03/23 11:48:00)  Microcyte: Moderate (2+), (02/03/23 11:48:00)  Ovalocyte: Moderate (2+), (02/03/23 11:48:00)  Platelet Estimate: Decreased. (02/03/23 11:48:00)  Platelet Morphology: Normal, (02/03/23 11:48:00)  Chemistry:  Sodium SerPl QN: 134 mmol/L Low (02/03/23 11:48:00)  Potassium SerPl QN: 4.5 mmol/L (02/03/23 11:48:00)  Chloride SerPl QN: 100 mmol/L (02/03/23 11:48:00)  Carbon Dioxide SerPl QN: 25 mmol/L (02/03/23 11:48:00)  Anion Gap: 9 mmol/L (02/03/23 11:48:00)  BUN SerPl QN: 48 mg/dL High (02/03/23 11:48:00)  Creatinine SerPl QN: 2.21 mg/dL High (02/03/23 11:48:00)  Estimated GFR (CKD-EPI, no race): 22 mL/min/1.73m2 Low (02/03/23 11:48:00)  Estimated CRCL (CG): 19 mL/min Low (02/03/23 11:48:00)  Glucose SerPl QN: 90 mg/dL (02/03/23 11:48:00)  Calcium Total SerPl QN: 9.4 mg/dL (02/03/23 11:48:00)  Alkaline Phos SerPl QN: 101 Units/L (02/03/23 11:48:00)  ALT SerPl QN: 25 Units/L (02/03/23 11:48:00)  AST SerPl QN: 31 Units/L (02/03/23 11:48:00)  Bilirubin Total SerPl QN: 1.9 mg/dL High (02/03/23 11:48:00)  Total Protein SerPl QN: 6.5 GM/dL (02/03/23 11:48:00)  Albumin SerPl QN: 3.8 GM/dL (02/03/23 11:48:00)  Troponin-I High Sensitivity: 33 ng/L High (02/03/23 13:00:00)  BNP Pl QN: 101 pg/mL High (02/03/23 11:48:00)  Urine Studies:  Color: Yellow (02/03/23 13:18:00)  Clarity: Clear (02/03/23 13:18:00)  Specific Gravity: 1.020 (02/03/23 13:18:00)  pH: 6.0 (02/03/23 13:18:00)  Protein: 100 Abnormal (02/03/23 13:18:00)  Glucose: NEGATIVE (02/03/23 13:18:00)  Ketones: NEGATIVE (02/03/23 13:18:00)  Bilirubin: SC Small Abnormal (02/03/23 13:18:00)  Hgb Ur: SMALL. Abnormal (02/03/23 13:18:00)  Nitrite: NEGATIVE (02/03/23 13:18:00)  Urobilinogen: NormalUro (02/03/23 13:18:00)  Leukocyte Esterase Ur: MODERATE. Abnormal (02/03/23 13:18:00)  WBC: 11-20 Abnormal (02/03/23 13:18:00)  RBC: 3-5 Abnormal (02/03/23 13:18:00)  Bacteria: Moderate Abnormal (02/03/23 13:18:00)  Squamous Epithelial: NONE (02/03/23 13:18:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (02/02/23 15:02:00)  Rapid Influenza A PCR: Not Detected (02/02/23 15:02:00)  Rapid Influenza B PCR: Not Detected (02/02/23 15:02:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 02/03/2023 12:07 - XR Chest PA or AP Portable  IMPRESSION:  Mediastinal contour and heart size are stable and within normallimits.  No focal consolidation, pulmonary edema, pneumothorax, orpleural effusion.  No new acute cardiopulmonary abnormalities sincethe previous examination.  Thank you for consulting with Radiology. Healthcare providerswishing to discuss this case further can contact the Emergency Radiology reading room at.    02/03/2023 14:26 - CT Abd/Pelvis W/O IV Contrast  IMPRESSION:1.  Negative for acute findings to explain the patient's left lowerquadrant pain. Persistent significant splenomegaly measuring up to4.2 cm and extending into the left pelvis which may contribute to thepatient's pain.2.  Inflammation in the right renal pelvis which may be artifacthowever can be seen in the setting of an ascending urinary tractinfection. Recommend correlation with urinalysis. Negative forhydronephrosis.3.  Chronic massive effect from the enlarged spleen appears to becausing mild atrophy of the left kidney. 4.  Additional chronic findings as described above. Thank you for consulting our team of subspecialty radiologists at Physicians Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 02/03/23 17:48  ________________________________________________________  NP     Addendum by  MD on February 03, 2023 18:05:57  (Verified)    General: Alert and oriented Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. Cardiovascular: Normal rate, Regular rhythm. Gastrointestinal: Soft, Non-tender. Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect        I saw and evaluated the patient in addition to the APP. I provided a substantive portion of the care for this patient. I personally performed in its entirety examfor this encounter. I have reviewed and verified this documentation and it accurately reflects our care.      MD   Hospital Medicine   Signature Line Electronically Signed on 02/03/23 18:06  ________________________________________________________  MD