Age: 66.0
Sex: F
Vaccine: RSV
Symptoms: Urine analysis abnormal, Urine ketone body absent, Urobilinogen urine, White blood cell count increased, White blood cells urine abnormal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on January 31, 2024 14:52   Verified By: MD on January 31, 2024 15:54    Encounter Info: Hospital, Emergency, 01/31/24 - 01/31/24    * Final Report *        Chief Complaint   Abdominal pain right lower quadrant  History of Present Illness/Subjective     66-year-old female came to ER with complaints of abdominal pain right lower quadrant patient does have a history of renal stones.  Patient is in the lower abdomen more so on the right side radiating to back.  Patient complains of nausea vomiting denies any fever or chills.  Patient underwent a CT of abdomen 5 minutes findings are consistent with acute appendicitis at retrocecal position.  Patient is here today for further treatment and evaluation.  Patient feels better after pain medication.  Patient is severe in nature aggravated by activity relieved by lying down.  Review of Systems     Constitutional: No fevers, no chills  Eyes: No changes in vision  Ears, Nose, Mouth, Throat: No sore throat  Respiratory: No shortness of breath, no cough  Cardiovascular: No chest pain, no edema  Gastrointestinal: abdominal pain,nausea, vomiting, no diarrhea  Genitourinary: No dysuria, no hematuria  Endocrine: No polyuria, no polydipsia  Musculoskeletal: No arthralgia, no myalgia  Skin: No rash  Neurologic: No headache, no focal weakness  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.6 °C (Oral)  BP: 136/72  HR: 65 (Peripheral)  RR: 15  SpO2: 94%  Oxygen Therapy: Room air  WT: 68.90 kg (WFC)   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    68.9 kg    01/31/24    Patient Height  Current Height:    157.5 cm    01/31/24        Constitutional: No acute distress, well-nourished  Head ENT and neck: Head is atraumatic and normocephalic, PERRLA, EOMI, JVD is negative sclera is nonicteric  Respiratory: Lungs CTAB  Cardiovascular: Regular rate and rhythm  Gastrointestinal: Soft, focal tenderness right lower quadrant, rebound is positive, non-distended  Skin: Intact, warm, dry no rashes  Neurologic: Alert & Oriented x 3, no cognitive impairment, no focal deficits  Psychiatric: Patient is cooperative mood and affect are appropriate    Assessment/Plan       Abdominal pain   R10.9    Acute appendicitis   K35.80    UTI (urinary tract infection)   N39.0    66-year-old female with history of bilateral mastectomy for breast cancer and diabetes.  Comes to ER with right lower quadrant pain.  Clinical exam at CT findings are consistent with acute appendicitis.  Will proceed with laparoscopic appendectomy.  Risk and benefit of the operation were explained in detail, including but not limited to infection hemorrhage and injury to surrounding structures.  Patient has been informed as deemed appropriate procedure could be converted to open.  Patient verbalized understanding and compliance with plan.  All question concerns were satisfactorily addressed  Code Status   None Recorded   Chronic Problem List    Anemia  B12 deficiency  Benign breast lumps  Bilateral sensorineural hearing loss  Bilateral tinnitus  Breast cancer  Breast wound  CAD (coronary artery disease)  Controlled type 2 diabetes mellitus with insulin therapy  Diabetic neuropathy  Diarrhea  Fracture of greater tuberosity of right humerus  H/O bone density study  Health care maintenance  Hematuria  History of anemia  History of breast cancer  HTN (hypertension)  Hypokalemia  Iron deficiency anemia  Lymphedema of arm  Mixed hyperlipidemia  Neuropathy  Obesity  Onychogryphosis  Onychomycosis  Osteoporosis  Osteoporosis of upper arm  Persistent insomnia  Physical deconditioning  Polyneuropathy in diseases classified elsewhere  Port-A-Cath in place  Post-menopause  Risk and functional assessment  Status post mastectomy  Type 2 diabetes mellitus with polyneuropathy  Vitamin D deficiency  Weight loss  Procedure/Surgical History  ?Diabetic retinal eye exam (01/11/2022) ?Eye examination (12/08/2021) ?Cholecystectomy (1973) ?Left breast biopsy ?Mammography - screening ?Mastectomy ?Microscopic examination of cervical Papanicolaou smear ?Percutaneous nephrolithostomy (open kidney stone removal thru pt back0   Surgical History Internal  02/02/2021    Portacath Removal.     MD  06/03/2020    Breast Reconstruction  (Bilateral)   MD  10/09/2019    Breast Reconstruction  (Bilateral, Left)   MD  10/12/2007    Perc Calyceal  (Left)   MD  Medications   Home Medications (16) Active  anastrozole 1 mg oral tablet 1 Tablet, Orally, Daily  aspirin 81 mg oral capsule 81 mg = 1 Capsule, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  carvedilol 3.125 mg oral tablet 3.125 mg = 1 Tablet, Orally, BID  glimepiride 2 mg oral tablet 2 mg = 1 Tablet, Orally, Daily  losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily, take in evening  Lunesta 2 mg oral tablet 2 mg = 1 Tablet, PRN, Orally, At Bedtime  metFORMIN 500 mg (Eqv-Glucophage XR) oral tablet, extended release 2 Tablet, Orally, BID  Misc Supplement , Magnesium 165mg gummies 1-am, 1-pm  Misc Supplement , vision vitamin- 1 daily  ONETOUCH VERIO IQ   STRP See Instructions, USE TO TEST BLOOD SUGAR TWO TIMES A DAY  OneTouch Verio Test Strips See Instructions, use to test blood sugar 3 times a day.  E11.42  Potassium Chloride (Eqv-Klor-Con M20) 20 mEq oral tablet, extended release 20 mEq = 1 Tablet, Orally, BID  Prenatal Multivitamins 1, Orally, Daily  Soliqua (insulin glargine-lixisenatide) 100/33 subcutaneous solution See Instructions, new dose***inject 40U in AM 30U PMmax daily dose 70Ud/c all other scripts  Tylenol PM 1 Tablet, Orally, At Bedtime  Active Scheduled Inpatient Medications  Sodium Chloride 0.9%  500 mL IV Continuous  75 mL/hr       One-Time Medications Given 01/30/24 00:00:00 TO 01/31/24 14:51:35  HYDROmorphone (HYDROmorphone Inj ED (1 mg/mL)), Injection, 0.5 mg, IV Push, ONCE, (1 DOSE 01/31/24 08:56:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, prn, Nausea/Vomiting IV - Use First, (1 DOSE 01/31/24 08:56:00)  piperacillin-tazobactam (Zosyn), Injection, 4.5 GM, IV Push, ONCE, (1 DOSE 01/31/24 11:11:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 01/31/24 08:23:00)  PRN Medications (0600 - 0559) from 01/30 - 01/31  HYDROmorphone, 0.5 mg, IV Push, Q10min, 0  Dose(s)   Allergies   Adhesive Bandage (Blisters)  Latex (Blisters)  Social History    Alcohol   Current, Liquor, 1-2 times per year   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Alone.   Nutrition/Health   Caffeine intake amount: 1/2 serving per day.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Alzheimer's disease: Mother.  Diabetes mellitus: Mother and Father.  Diabetes mellitus type 2: Brother.  Heart attack: Brother (Dx at 57).  Heart disease: Father.  Skin cancer: Father.  Thyroid disease...: Sister.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 12.2 k/cumm High (01/31/24 08:22:00)  RBC: 4.36 million/cumm (01/31/24 08:22:00)  Hgb: 12.4 GM/dL (01/31/24 08:22:00)  Hct: 36.5 % (01/31/24 08:22:00)  MCV: 84 fL (01/31/24 08:22:00)  MCH: 28.4 pg (01/31/24 08:22:00)  MCHC: 33.9 GM/dL (01/31/24 08:22:00)  RDW: 15.2 % High (01/31/24 08:22:00)  Platelet: 302 k/cumm (01/31/24 08:22:00)  MPV: 7 fL (01/31/24 08:22:00)  Neutrophils %: 78 % (01/31/24 08:22:00)  Lymphocytes %: 12 % (01/31/24 08:22:00)  Monocytes %: 8 % (01/31/24 08:22:00)  Eosinophils %: 1 % (01/31/24 08:22:00)  Basophils %: 0 % (01/31/24 08:22:00)  Absolute Neutrophil: 9.5 k/cumm High (01/31/24 08:22:00)  Absolute Lymphocyte: 1.4 k/cumm (01/31/24 08:22:00)  Absolute Monocyte: 1 k/cumm (01/31/24 08:22:00)  Absolute Eosinophil: 0.2 k/cumm (01/31/24 08:22:00)  Absolute Basophil: 0 k/cumm (01/31/24 08:22:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (01/31/24 08:22:00)  Potassium SerPl QN: 4.1 mmol/L (01/31/24 08:22:00)  Chloride SerPl QN: 101 mmol/L (01/31/24 08:22:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (01/31/24 08:22:00)  Anion Gap: 8 mmol/L (01/31/24 08:22:00)  BUN SerPl QN: 24 mg/dL High (01/31/24 08:22:00)  Creatinine SerPl QN: 0.76 mg/dL (01/31/24 08:22:00)  Estimated GFR (CKD-EPI, no race): 86 mL/min/1.73m2 (01/31/24 08:22:00)  Estimated CRCL (CG): 66 mL/min (01/31/24 08:22:00)  Glucose SerPl QN: 162 mg/dL High (01/31/24 08:22:00)  Calcium Total SerPl QN: 10.1 mg/dL (01/31/24 08:22:00)  Alkaline Phos SerPl QN: 52 Units/L (01/31/24 08:22:00)  ALT SerPl QN: 23 Units/L (01/31/24 08:22:00)  AST SerPl QN: 19 Units/L (01/31/24 08:22:00)  Bilirubin Total SerPl QN: 0.4 mg/dL (01/31/24 08:22:00)  Total Protein SerPl QN: 6.7 GM/dL (01/31/24 08:22:00)  Albumin SerPl QN: 4.5 GM/dL (01/31/24 08:22:00)  Magnesium SerPl QN: 2.1 mg/dL (01/31/24 08:22:00)  Amylase SerPl QN: 28 Units/L (01/31/24 08:22:00)  Lipase SerPl QN: 29 Units/L (01/31/24 08:22:00)  Troponin-I High Sensitivity: 3 ng/L (01/31/24 09:32:00)  Gluc-Strip, POC: 132 mg/dL High (01/31/24 10:26:00)  Coagulation:  PT: 11 seconds (01/31/24 08:22:00)  INR: 0.96 (01/31/24 08:22:00)  aPTT: 37.1 seconds (01/31/24 08:22:00)  Urine Studies:  Color: Colorless (01/31/24 09:57:00)  Clarity: Clear (01/31/24 09:57:00)  Specific Gravity: 1.036 High (01/31/24 09:57:00)  pH: 8 (01/31/24 09:57:00)  Protein: NEGATIVE (01/31/24 09:57:00)  Glucose: Normal (01/31/24 09:57:00)  Ketones: NEGATIVE (01/31/24 09:57:00)  Bilirubin: NEGATIVE (01/31/24 09:57:00)  Hgb Ur: NEGATIVE (01/31/24 09:57:00)  Nitrite: Positive 1+ Abnormal (01/31/24 09:57:00)  Urobilinogen: Normal (01/31/24 09:57:00)  Leukocyte Esterase Ur: Small75 Abnormal (01/31/24 09:57:00)  WBC: 11-20 Abnormal (01/31/24 09:57:00)  RBC: 3-5 Abnormal (01/31/24 09:57:00)  Bacteria: TRACE. (01/31/24 09:57:00)  Yeast Ur: PRESENT. Abnormal (01/31/24 09:57:00)  Squamous Epithelial: NONE (01/31/24 09:57:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (01/31/24 11:48:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (01/31/24 11:48:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 01/31/2024 08:42 - XR Chest PA or AP Portable  IMPRESSION:1.  Mild left midlung infiltrate or possibly postradiation scarring.There is no recent imaging available for comparison.    01/31/2024 09:11 - CT Abd/Pelvis W/IV Contrast  IMPRESSION: 1.  Status post cholecystectomy.2.  Chronic cortical scarring in the left kidney.3.  There is a 0.8 cm indeterminate hypodense lesion in the rightkidney. A follow-up CT scan of the abdomen without and withintravenous contrast in 6 months is recommended for furthercharacterization.4.  Acute, uncomplicated retrocecal appendicitis.               Signature Line Electronically Signed on 01/31/24 15:54 ________________________________________________________ MD