Age: 59.0
Sex: F
Vaccine: FLU4
Symptoms: Urine ketone body absent, Urine leukocyte esterase positive, Urobilinogen urine, Wheezing, White blood cell count normal
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: Employee on October 29, 2022 11:08    Verified By: MD on October 29, 2022 13:54    Encounter Info: Hospital, Emergency, 10/29/22 - 10/29/22    * Final Report *        Basic Information  Time Seen: MD / 10/29/2022 11:00  Chief Complaint  Shortness of breath (Complaint of)  History of Present Illness     Time Seen: 10/29/22 11:02:03  59 year old female with hx of asthma, bipolar, schizophrenia, and depression presents to the ED via private vehicle complaining of L-sided flank/abdominal pain onset 1 month ago. Pain is intermittent in nature. Pain is sharp. Worsens with inspiration. Pt endorses associated dyspnea, hematuria, and nausea. Denies emesis. Pt states she is currently being worked up by her PCP for gallstones. Pt reports previous hx of kidney stones. Pt notes she is attempting to quit. Pt is no longer on Plavix.  Review of Systems      Respiratory: +dyspnea Gastrointestinal: +L-sided abdominal/flank pain, +nausea, no emesis Genitourinary: +hematuria  Additional review of systems information: All other systems reviewed and otherwise negative.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.4 DegC  Heart Rate:       99 bpm  Resp Rate:       28 br/min  BP #1:       157 / 86 mmHg  SpO2 (%):       93 %  O2 Device:       Room air     Height CM: 157.5 cm  Weight KG: 59.4 kg  Ideal Body Weight: 50.12 kg     General: Alert, no acute distress Head: Normocephalic, atraumatic Eyes: Pupils equal, round, and reactive to light, extraocular movements are intact Cardiovascular: Regular rate and rhythm, no murmur Respiratory:  slight wheezing, hyperventilating which improved over the course of the interview Gastrointestinal: Soft, nontender, non-distended Musculoskeletal: Normal range of motion Neurological: Alert and oriented to person, place, time, and situation, no focal neurological deficits  Medical Decision Making     Rationale:  Diff dx includes but not limited to: renal stone vs less likely pneumonia vs less likely diverticulitis vs gastritis vs less likely cardiogenic cause vs psychosomatic cause.  Will get labs, EKG, and CXR and give pain meds.  Likely dispo: discharge if workup if negative.  10/29/22 13:42:51 Rechecked pt. Updated pt on all current labs and imaging, which are not indicative of an acute abnormalities. Pt feels improved. Counselled pt on follow-up with PCP. Discussed dx and plan for discharge. Patient understands and agrees with plan. All questions addressed.            Condition     Stable  Disposition: 10/29/22 13:42:33  discharged to home  Counseled  Counseled patient regarding diagnosis, regarding diagnostic results, regarding treatment plan. Patient indicated understanding of instructions.  Scribe Attestation:  I, acting as scribe for Dr at 10/29/22 11:02:38 Signed by Scribe, at 10/29/22 11:02:38  I, MD, have reviewed this note and attest to its contents.  It was prepared under my direction and at the time of my signature I will have reviewed it in its entirety and edited where appropriate.  Assessment/Plan       Left flank pain   R10.9     Patient Education   Flank Pain, Uncertain Cause  Follow Up        With  When  Contact Information        NP, FAM Within 1 to 2 weeks Healthcare       Additional Instructions:          Chronic Problem List    Closed fracture of proximal end of left humerus  Fracture of proximal end of left humerus  Fracture of scaphoid of left wrist  Smoker  Procedure/Surgical History  ?bladder surgery (2016) ?Colonoscopy (05/24/2013) ?Back ?BREAST IMPLANT REMOVAL ?HYSTERECTOMY ?Tonsillectomy  Surgical History Internal  02/12/2020    Wound Debridement.    MD  Medications  Home Medications (17) Active clopidogrel 75 mg oral tablet  Depakote ER 500 mg oral tablet, extended release 500 mg = 1 Tablet, Orally, Daily DiazePAM 5 mg oral tablet  gabapentin 300 mg oral capsule  ibuprofen 600 mg oral tablet 600 mg = 1 Tablet, PRN, Orally, 4 Times Daily Latuda 120 mg oral tablet  olanzapine 15 mg oral tablet  ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, Inhalation, Q6H Santyl topical 250 Units/GM ointment See Instructions, APPLY TO THE AFFECTED AREA as directed by THE wound center Spiriva Respimat 1.25 mCg/inh inhalation aerosol  traZODONE 150 mg oral tablet  Trelegy Ellipta  Trelegy Ellipta , Inhalation, Daily Trelegy Ellipta , Inhalation, Daily Trelegy Ellipta , Inhalation, Daily Trelegy Ellipta inhalation powder 1 Puff, Inhalation, Daily Zyprexa   Medication Administration   Given  fentaNYL, 50 mCg, IV Push  ondansetron, 4 mg, IV Push  Allergies   penicillins  Social History    Alcohol   Denies   Substance Abuse   Denies   Tobacco   Tobacco Use: Current Every Day Smoker. Cigarettes, 1 packs per day.  Family History   Family history is unknown  Lab Results      Hemogram-Platelets-WBC Differential FS  LATEST RESULTS        WBC  10/29/22 11:22  8.3        RBC  10/29/22 11:22  4.54        Hgb  10/29/22 11:22  13.7        Hct  10/29/22 11:22  41.3        MCV  10/29/22 11:22  91        MCH  10/29/22 11:22  30.1        MCHC  10/29/22 11:22  33.1        RDW  10/29/22 11:22  14.3        Platelet  10/29/22 11:22  269        MPV  10/29/22 11:22  7.4        Neutrophils %  10/29/22 11:22  60        Lymphocytes %  10/29/22 11:22  28        Monocytes %  10/29/22 11:22  6        Eosinophils %  10/29/22 11:22  5        Basophils %  10/29/22 11:22  1        Absolute Neutrophil  10/29/22 11:22  5.0        Absolute Lymphocyte  10/29/22 11:22  2.3        Absolute Monocyte  10/29/22 11:22  0.5        Absolute Eosinophil  10/29/22 11:22  0.4  High        Absolute Basophil  10/29/22 11:22  0.1          Routine Chemistry Tests FS  LATEST RESULTS        Sodium SerPl QN  10/29/22 11:22  135        Potassium SerPl QN  10/29/22 11:22  4.0        Chloride SerPl QN  10/29/22 11:22  101        Carbon Dioxide SerPl QN  10/29/22 11:22  27        Anion Gap  10/29/22 11:22  7        BUN SerPl QN  10/29/22 11:22  17        Creatinine SerPl QN  10/29/22 11:22  0.85        Estimated GFR (CKD-EPI, no race)  10/29/22 11:22  79        Estimated CRCL (CG)  10/29/22 11:22  61        Glucose SerPl QN  10/29/22 11:22  94        Calcium Total SerPl QN  10/29/22 11:22  10.3        Alkaline Phos SerPl QN  10/29/22 11:22  70        ALT SerPl QN  10/29/22 11:22  10        AST SerPl QN  10/29/22 11:22  13        Bilirubin Total SerPl QN  10/29/22 11:22  0.3        Total Protein SerPl QN  10/29/22 11:22  7.1        Albumin SerPl QN  10/29/22 11:22  4.4        Troponin-I High Sensitivity  10/29/22 11:22  3          Urinalysis FS  LATEST RESULTS        Color  10/29/22 12:46  Yellow        Clarity  10/29/22 12:46  Clear        Specific Gravity  10/29/22 12:46  1.010        pH  10/29/22 12:46  6.5        Protein  10/29/22 12:46  Negative        Glucose  10/29/22 12:46  Negative        Ketones  10/29/22 12:46  Negative        Bilirubin  10/29/22 12:46  Negative        Hgb Ur  10/29/22 12:46  Negative        Nitrite  10/29/22 12:46  Negative        Urobilinogen  10/29/22 12:46  Normal        Leukocyte Esterase Ur  10/29/22 12:46  Trace Abnormal          Molecular Diagnostic Tests  LATEST RESULTS        COVID 19 Specimen Source  10/29/22 11:22  Nasal        Coronavirus SARS-CoV2 Rapid  10/29/22 11:22  Not Detected      Diagnostic Results  CT Abd/Pelvis W/O IV Contrast    10/29/22 11:59:02  IMPRESSION:  1. No acute findings in the abdomen or pelvis.     Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss  this case further can contact the Abdominal Imaging Reading Room. For after-hours or emergency department cases, please  call    Electronically Signed by:     Signed By:  MD     ************************************************** XR Chest PA or AP Portable    10/29/22 11:39:15  IMPRESSION:  1. No acute findings in the chest.   Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discuss  this case further can contact the Cardiothoracic Reading Room. For after-hours or emergency department cases, please  call .   Electronically Signed by:     Signed By: MD  EKG  Time: 10/29/2022 1054 Rate: 73 bpm Rhythm: normal sinus rhythm Intervals: within normal limits EP Interp: no acute ischemic findings      Signature Line Electronically Signed on 10/29/22 13:45  ________________________________________________________   Electronically Signed on 10/29/22 13:54  ________________________________________________________ MD