Age: 45.0
Sex: F
Vaccine: COVID19
Symptoms: Nitrite urine absent, Occult blood negative, Otitis media acute, Pain in extremity, Platelet count decreased
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on July 24, 2023 16:26   Verified By: MD on July 24, 2023 16:26  Encounter Info: Hospital, Inpatient, 07/24/23 -     * Final Report *  Document Has Been Revised          History of Present Illness/Subjective     This is a 47 yr old, with past medical history of MS, presents with complains of chest pain and arm pain. the arm pain was first on the right arm and then moved to the left arm. more pain and uncomfortable feeling, tells me it was different for her usual MS flares. Follows MD for her MS and thats the only doctor she sees. she never Experiences blood in stool, urine. ulcers, felt pretty fine before this.  she takes  Aubagio for long term maintenance For MS and lyrica for Migraine.   The patient is vitally stable,    In the ED the patient was noted to have dropping hemoglobin down to 6.7 after which she was transfused, potassium of 2.9 which could be giving her uncomfortable pain and stretching feeling in the arms and she has a protein gap.  The patient is not iron deficient stool is negative for occult blood  Review of Systems     13 point review of system is negative except what is mentioned above  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.7 °C (Oral)  BP: 131/85  HR: 95 (Monitored)  RR: 20  SpO2: 95%  Oxygen Therapy: Room air  WT: 69.10 kg (WFC)   Hemodynamics   Neurologic   Patient Weight  Current Daily Weight:    69.1 kg    07/24/23    Patient Height  Current Height:    162.6 cm    07/24/23        Constitutional:  No acute distress,  Eyes:  PERRLA,  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, non-tender, non-distended  Musculoskeletal:  No joint swelling, no deformity, intact ROM  Integumentary:  Intact, warm, dry no rashes  Neurologic: Alert & Oriented   Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       1. Anemia   D64.9  The patient is admitted here for anemia, I will add on the hemolytic work-up.  She takes Aubagio for long-term maintenance of her MS.  This medication does have a side effect of anemia and thrombocytopenia.  I will touch base with the patient's neurologist regarding this  In the meanwhile we will multiple myeloma work-up should be done as the patient has a protein gap.  -Maintain hemoglobin levels greater than 7  -CBC every 6 for now  -B12 and folate levels  -LDH and haptoglobin AND PERIPHERAL Smear  -Hematology consult tomorrow  -Hold heparin   2. Multiple Sclerosis   G35  - History of MS  -Aubagio for a long time   3. Thrombocytopenia   D69.6  - Thrombocytopenia is mild, continue to monitor   4. Foraminal stenosis of cervical region   M48.02  There is now moderate right foraminal narrowing at C5-6 with probable impingement of the exiting nerve roots at these foramina. ( reports from 6/16/23)   5. Hypokalemia   E87.6  - Hypokalemia of 2.9, replete and monitor , no reports of Diarrhea.   Orders:   **Protein Ur Tm QN  Beta 2 Micro SerPl QN  CBC  Ferritin SerPl QN  Folate SerPl QN  Free Light Chains Ser QN  Free Light Chains Ur QN  Immunoglobulin Profile  Iron SerPl QN  Protein Elp Ser IFE Rflx  Protein Elp Urn IFE Rflx  Vitamin B12 SerPl QN   Code Status   None Recorded   Chronic Problem List    Acute on chronic blood loss anemia  Acute suppurative otitis media of left ear without spontaneous rupture of ear drum  Elevated blood protein  Hyperalbuminemia  Hypokalemia  Multiple Sclerosis  Pneumonia  Thrombocytopenia  Procedure/Surgical History  ?Edotracheal Intubation (03/01/2017) ?Cesarean Section     Medications   Home Medications (9) Active  amantadine 100 mg oral capsule 100 mg = 1 Capsule, Orally, BID  Aubagio 14 mg oral tablet 14 mg, Orally, Daily  baclofen 5 mg oral tablet 10 mg = 2 Tablet, Orally, TID  Lyrica 200 mg oral capsule 200 mg = 1 Capsule, Orally, BID  Pepcid 20 mg oral tablet 20 mg = 1 Tablet, Orally, BID  predniSONE 50 mg oral tablet See Instructions, 25 tablets orally daily with food for acute MS relapse  SUMAtriptan , ONCE  Zeposia 0.23 mg-0.46 mg oral capsule See Instructions, 0.23mg orally daily on days 1-4, then 0.46mg daily on days 5-7.  Then begin maintenance dose on day 8.  Zeposia 0.92 mg oral capsule 0.92 mg = 1 Capsule, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 07/23/23 00:00:00 TO 07/24/23 16:25:47  None Reported  PRN Medications (0600 - 0559) from 07/23 - 07/24  None Reported  Allergies   NKA  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use 26-50 inhales/day.   Home/Environment   Lives with Children, Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Diabetes mellitus type 2: Negative: Mother and Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 4.2 k/cumm (07/24/23 16:14:00)  RBC: 2.22 million/cumm Low (07/24/23 16:14:00)  Hgb: 7.5 GM/dL Low (07/24/23 16:14:00)  Hct: 22.2 % Low (07/24/23 16:14:00)  MCV: 100 fL High (07/24/23 16:14:00)  MCH: 33.7 pg (07/24/23 16:14:00)  MCHC: 33.8 GM/dL (07/24/23 16:14:00)  RDW: 20.2 % High (07/24/23 16:14:00)  Platelet: 137 k/cumm Low (07/24/23 16:14:00)  MPV: 7.4 fL (07/24/23 16:14:00)  Neutrophils %: 57 % (07/24/23 05:13:00)  Lymphocytes %: 28 % (07/24/23 05:13:00)  Monocytes %: 14 % (07/24/23 05:13:00)  Eosinophils %: 0 % (07/24/23 05:13:00)  Basophils %: 0 % (07/24/23 05:13:00)  Absolute Neutrophil: 3 k/cumm (07/24/23 05:13:00)  Absolute Lymphocyte: 1.4 k/cumm (07/24/23 05:13:00)  Absolute Monocyte: 0.7 k/cumm (07/24/23 05:13:00)  Absolute Eosinophil: 0 k/cumm (07/24/23 05:13:00)  Absolute Basophil: 0 k/cumm (07/24/23 05:13:00)  Reticulocyte Count: 2.1 % (07/24/23 05:13:00)  Absolute Retic Number: 39.9 k/cumm (07/24/23 05:13:00)  Chemistry:  Sodium SerPl QN: 130 mmol/L Low (07/24/23 05:13:00)  Potassium SerPl QN: 2.9 mmol/L Critical (07/24/23 05:13:00)  Chloride SerPl QN: 103 mmol/L (07/24/23 05:13:00)  Carbon Dioxide SerPl QN: 24 mmol/L (07/24/23 05:13:00)  Anion Gap: 3 mmol/L (07/24/23 05:13:00)  BUN SerPl QN: 24 mg/dL High (07/24/23 05:13:00)  Creatinine SerPl QN: 0.86 mg/dL (07/24/23 05:13:00)  Estimated GFR (CKD-EPI, no race): 84 mL/min/1.73m2 (07/24/23 05:13:00)  Estimated CRCL (CG): 78 mL/min (07/24/23 05:13:00)  Glucose SerPl QN: 103 mg/dL High (07/24/23 05:13:00)  Calcium Total SerPl QN: 8.7 mg/dL (07/24/23 05:13:00)  Alkaline Phos SerPl QN: 31 Units/L (07/24/23 05:13:00)  ALT SerPl QN: 14 Units/L (07/24/23 05:13:00)  AST SerPl QN: 18 Units/L (07/24/23 05:13:00)  Bilirubin Direct SerPl QN: <0.1 (07/24/23 05:13:00)  Bilirubin Total SerPl QN: 0.2 mg/dL (07/24/23 05:13:00)  Total Protein SerPl QN: 14.1 GM/dL High (07/24/23 05:13:00)  Albumin SerPl QN: 2.9 GM/dL Low (07/24/23 05:13:00)  Troponin-I High Sensitivity: 7 ng/L (07/24/23 05:13:00)  Iron SerPl QN: 130 mCg/dL (07/24/23 05:13:00)  UIBC Meas SerPl QN: 155 mCg/dL (07/24/23 05:13:00)  TIBC Ser QN: 285 mCg/dL (07/24/23 05:13:00)  % Saturation: 46 % (07/24/23 05:13:00)  Ferritin SerPl QN: 42.6 ng/mL (07/24/23 05:13:00)  Haptoglobin Ser QN: 122 mg/dL (07/24/23 05:13:00)  Coagulation:  PT: 18.3 seconds High (07/24/23 05:13:00)  INR: 1.6 High (07/24/23 05:13:00)  Urine Studies:  Color: Yellow (07/24/23 06:00:00)  Clarity: Clear (07/24/23 06:00:00)  Specific Gravity: 1.025 (07/24/23 06:00:00)  pH: 6.0 (07/24/23 06:00:00)  Protein: TRACE. Abnormal (07/24/23 06:00:00)  Glucose: NEGATIVE (07/24/23 06:00:00)  Ketones: NEGATIVE (07/24/23 06:00:00)  Bilirubin: NEGATIVE (07/24/23 06:00:00)  Hgb Ur: SMALL. Abnormal (07/24/23 06:00:00)  Nitrite: NEGATIVE (07/24/23 06:00:00)  Urobilinogen: NormalUro (07/24/23 06:00:00)  Leukocyte Esterase Ur: NEGATIVE (07/24/23 06:00:00)  WBC: 6-10 Abnormal (07/24/23 06:00:00)  RBC: 3-5 Abnormal (07/24/23 06:00:00)  Bacteria: Moderate Abnormal (07/24/23 06:00:00)  Squamous Epithelial: Moderate (07/24/23 06:00:00)  Mucous: PRESENT. (07/24/23 06:00:00)  Hyaline Casts: 3-5 (07/24/23 06:00:00)  All Other Labs:  Specimen Type Occult Blood: Stool (07/24/23 05:47:00)  Occult Blood Stool: Negative (07/24/23 05:47:00)  ABO Rh: O Neg (07/24/23 05:47:00)  Indirect Coombs: Neg (07/24/23 05:47:00)  COVID 19 Specimen Source: Nasopharyngeal (07/24/23 07:56:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (07/24/23 07:56:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 07/24/2023 05:21 - XR Chest PA or AP Portable  IMPRESSION: 1.  No acute findings in the chest.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 07/24/23 16:26 ________________________________________________________ MD  Electronically Signed on 07/24/23 16:28 ________________________________________________________ MD  Electronically Signed on 07/24/23 17:13 ________________________________________________________ MD