Age: 19.0
Sex: F
Vaccine: COVID19
Symptoms: Urinary incontinence, Urinary sediment present, Urine ketone body absent, Urobilinogen urine, Vertigo
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on January 29, 2024 11:57    Verified By: NP on January 29, 2024 11:57   Encounter Info: Hospital, Inpatient, 01/29/24 -     * Final Report *  Document Contains Addenda        Chief Complaint   syncope  History of Present Illness/Subjective     This is a 21 year old patient with a past medical history significant for chrons disease, IDA,  hypothyroidism, that presented to ED on 01/29/2024 via EMS from work with c/o syncope and is being admitted to observation for sepsis, syncope, colitis, and colon abscess.   Patient states that she works as a caregiver.  She stood up to help her patient go to the bathroom.  Shortly after standing up, she started to feel lightheaded with mild chest pain.  She then passed out. She does not believe she was unconscious for very long.  EMS reports that the patient had LOC of 15 seconds.  Patient reports falling and hitting her head when she passed out.  She endorses urinating and vomiting on herself when she passed out.  She endorses dizziness which describes as vertigo since passing out.  She also endorses right lower quadrant abdominal pain intermittently since last week, now more severe.  She endorses persistent nausea and vomiting since falling and hitting her head.  She also endorses severe headaches since syncopizing.  No chest pain currently.  She denies any other complaints.  No fever, shortness of breath, cough, diarrhea constipation, urinary symptoms, lower extremity pain or swelling.  No recent travel or sick contacts.  Denies pregnancy. CBC is unremarkable other than hemoglobin 11.9 and hematocrit 34.8.  CMP is unremarkable other than potassium 3.1 and a glucose of 101.  ALT is 6. Negative pregnancy test.  Urinalysis shows a specific gravity 1.019, pH of 6.0 small leukocyte esterase. patient is febrile with temps at 38, tachy in the low 100s, and slightly hypotensive with systolic pressures in the high 90s. Per radiology report, CT abdomen pelvis shows wall thickening and pericolonic fat stranding involving the rectum, and to a lesser degree the distal sigmoid colon, concerning for rectosigmoid colitis.  This could be infectious or inflammatory.  There is a small extraluminal air and fluid collection measure approximately 2.1 x 1.0 cm in greatest axial dimension approximate 0.8 cm in greatest dimension.  This is concerning for small extraluminal abscess.  There is approximately a 4.5 x 4.1 x 5.2 cm left ovarian cyst which was also present in 2022.  This could be recurrent or residual cyst. Covid and Influenza A and B are not detected. ED provider discussed case with GI who recommended surgery consult and colonoscopy in one month. Surgery agrees to admission here and will consult.       Review of Systems     Constitutional:  + Fevers,  no chills,  no sweats +dizziness Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No ear pain,  no nasal congestion,  no sore throat Respiratory:  No shortness of breath,  no cough,  no wheeze Cardiovascular:  No chest pain,  no palpitations,  no edema Gastrointestinal:  + Abdominal pain,  no nausea,  no vomiting,  no diarrhea,  no constipation Genitourinary:  No frequency,  no urgency,  no dysuria,  no hematuria Hematologic/Lymphatic:  No bruising,  no enlarged lymph nodes Allergic/Immunologic:  No hives Endocrine:  No cold intolerance,  no heat intolerance,  no polyuria,  no polydipsia Musculoskeletal:  No arthralgia,  no myalgia Skin:  No rash,  no pruritus Neurological:  No headache,  no focal weakness,  no numbness Psychiatric:  No anxiety,  no depression  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 38.3 °C (Oral)  TMIN: 37.9 °C (Oral)  TMAX: 38.3 °C (Oral)  BP: 94/57  BP: 111/61(Supine)  BP: 107/75(Sitting)  BP: 112/72(Standing)  BP: 110/70(Standing 3 Min)  HR: 85 (Monitored)  HR: 85 (Peripheral)  RR: 15  SpO2: 98%  Oxygen Therapy: Room air  WT: 66.10 kg (WFC)    Hemodynamics  Hemodynamic Monitoring Device: Bedside Monitor  Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    66.1 kg    01/29/24    Patient Height  Current Height:    153 cm    01/29/24         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 x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan     This is a 21 year old patient with a past medical history significant for chrons disease, IDA,  hypothyroidism, that presented to ED on 01/29/2024 via EMS from work with c/o syncope and is being admitted to observation for sepsis, syncope, colitis, and colon abscess.    1. Sepsis   A41.9  SIRS criteria met, Fever greater than 38 deg C, Heart rate greater than 90.  uspected source- colon abscess.  No signs of organ failure.  slighlty hypotensive but map is stable above 65. will continue to monitor and maintain MAP above 65  Blood cultures pending  Broad spectrum IV antibiotics started, will treat with IV zosyn.  IV fluids bolus given in ED, will continue with NS at 100 ml/ hr.    procal pending   2. Abscess of sigmoid colon   K63.0  surgery consult pending   see above  SCDs for VTE prophylaxis given that surgery could be a possibility   NPO with ice chips.  will defer to surgery for diet escalation    3. Syncope   R55  likely 2/2 hypovolemia from sepsis.    Follow treatment plan as noted above   telemetry   will obtain an echo to r/o cardiogenic causes.    4. Hypokalemia   E87.6  monitor and replace    5. Crohn disease   K50.90  see above    6. IDA (iron deficiency anemia)   D50.9   stable for baseline    7. Vitamin B12 deficiency   E53.8   continue to follow outpatient    8. Hypothyroidism   E03.9   resume home synthroid       Observation, medical floor  Daily labs - CBC, CMP Daily   NPO Diet  IV fluids 100ml/hr  Telemetry  Full Code Status  VTE Prophylaxis - SCDS     Code Status   Full code   Chronic Problem List    Crohn disease  IDA (iron deficiency anemia)  Vitamin B12 deficiency  Procedure/Surgical History  ?colonoscopy (03/22/2021) ?EGD (03/22/2021) ?None   Surgical History Internal  03/22/2021    Colonscpy   MD  Medications   Home Medications (6) Active  dicyclomine 20 mg oral tablet 1 Tablet, Orally, 4 Times Daily  EpiPen 2-Pak 0.3 mg injectable solution 0.3 mg, PRN, IM, ONCE  Euthyrox 100 mCg (0.1 mg) oral tablet , TAKE 1 TABLET BY MOUTH ONCE DAILY  Sprintec 0.25 mg-35 mCg oral tablet 1 Tablet, Orally, Daily  Stelara PFS 90 mg/mL subcutaneous solution 90 mg = 1 mL, Subcutaneous, Every 8 Weeks, Start after 8 weeks of the infusion.  Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q8H  Active Scheduled Inpatient Medications  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 500 mL, IVPB, ONCE, Start: 01/29/24 12:00:00  ondansetron, Injection, 4 mg, IV Push, ONCE, prn, Nausea/Vomiting IV - Use First, Start: 01/29/24 08:59:00    One-Time Medications Given 01/28/24 00:00:00 TO 01/29/24 11:56:50  acetaminophen, Tablet, 1,000 mg, Orally, ONCE, (1 DOSE 01/29/24 08:16:00)  ceftRIAXone, Injection, 1 GM, IV Push, ONCE, (1 DOSE 01/29/24 06:52:00)  fentaNYL, Injection, 25 mCg, IV Push, ONCE, (1 DOSE 01/29/24 09:16:00)  metroNIDAZOLE, Infusion, 500 mg, IVPB, ONCE, (1 DOSE 01/29/24 06:47:00)  morphine, Injection, 4 mg, IV Push, ONCE, (1 DOSE 01/29/24 04:21:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 01/29/24 04:21:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 01/29/24 04:20:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 01/29/24 09:16:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 01/29/24 10:42:00)  PRN Medications (0600 - 0559) from 01/28 - 01/29  fentaNYL, 25 mCg, IV Push, Q10min, 0  Dose(s)   Allergies   Bee Sting  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Student   Home/Environment   Lives with Aunt and Uncle .   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.2 k/cumm (01/29/24 03:59:00)  RBC: 4.12 million/cumm (01/29/24 03:59:00)  Hgb: 11.9 GM/dL Low (01/29/24 03:59:00)  Hct: 34.8 % Low (01/29/24 03:59:00)  MCV: 85 fL (01/29/24 03:59:00)  MCH: 29 pg (01/29/24 03:59:00)  MCHC: 34.3 GM/dL (01/29/24 03:59:00)  RDW: 13.4 % (01/29/24 03:59:00)  Platelet: 373 k/cumm (01/29/24 03:59:00)  MPV: 5.9 fL Low (01/29/24 03:59:00)  Neutrophils %: 90 % (01/29/24 03:59:00)  Lymphocytes %: 5 % (01/29/24 03:59:00)  Monocytes %: 4 % (01/29/24 03:59:00)  Eosinophils %: 1 % (01/29/24 03:59:00)  Basophils %: 0 % (01/29/24 03:59:00)  Absolute Neutrophil: 8.2 k/cumm High (01/29/24 03:59:00)  Absolute Lymphocyte: 0.5 k/cumm Low (01/29/24 03:59:00)  Absolute Monocyte: 0.3 k/cumm (01/29/24 03:59:00)  Absolute Eosinophil: 0.1 k/cumm (01/29/24 03:59:00)  Absolute Basophil: 0 k/cumm (01/29/24 03:59:00)  Chemistry:  Sodium SerPl QN: 136 mmol/L (01/29/24 03:59:00)  Potassium SerPl QN: 3.1 mmol/L Low (01/29/24 03:59:00)  Chloride SerPl QN: 102 mmol/L (01/29/24 03:59:00)  Carbon Dioxide SerPl QN: 25 mmol/L (01/29/24 03:59:00)  Anion Gap: 9 mmol/L (01/29/24 03:59:00)  BUN SerPl QN: 7 mg/dL (01/29/24 03:59:00)  Creatinine SerPl QN: 0.9 mg/dL (01/29/24 03:59:00)  Estimated GFR (CKD-EPI, no race): >90 (01/29/24 03:59:00)  Estimated CRCL (CG): 84 mL/min (01/29/24 03:59:00)  Glucose SerPl QN: 101 mg/dL High (01/29/24 03:59:00)  Calcium Total SerPl QN: 8.8 mg/dL (01/29/24 03:59:00)  Alkaline Phos SerPl QN: 61 Units/L (01/29/24 03:59:00)  ALT SerPl QN: 6 Units/L Low (01/29/24 03:59:00)  AST SerPl QN: 13 Units/L (01/29/24 03:59:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (01/29/24 03:59:00)  Total Protein SerPl QN: 7.3 GM/dL (01/29/24 03:59:00)  Albumin SerPl QN: 3.9 GM/dL (01/29/24 03:59:00)  Lipase SerPl QN: 9 Units/L (01/29/24 03:59:00)  Troponin-I High Sensitivity: <3 (01/29/24 03:59:00)  Lactate Venous Pl QN: 2 mmol/L (01/29/24 10:40:00)  Urine Studies:  Pregnancy Test Urine: Negative (01/29/24 04:48:00)  Color: Light-Yellow (01/29/24 04:48:00)  Clarity: Clear (01/29/24 04:48:00)  Specific Gravity: 1.019 (01/29/24 04:48:00)  pH: 6 (01/29/24 04:48:00)  Protein: NEGATIVE (01/29/24 04:48:00)  Glucose: Normal (01/29/24 04:48:00)  Ketones: NEGATIVE (01/29/24 04:48:00)  Bilirubin: NEGATIVE (01/29/24 04:48:00)  Hgb Ur: NEGATIVE (01/29/24 04:48:00)  Nitrite: NEGATIVE (01/29/24 04:48:00)  Urobilinogen: Normal (01/29/24 04:48:00)  Leukocyte Esterase Ur: Small75 Abnormal (01/29/24 04:48:00)  WBC: 6-10 Abnormal (01/29/24 04:48:00)  RBC: 0-2 (01/29/24 04:48:00)  Bacteria: NONE (01/29/24 04:48:00)  Squamous Epithelial: Few (01/29/24 04:48:00)  Hyaline Casts: 0-2 (01/29/24 04:48:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (01/29/24 10:10:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (01/29/24 10:10:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (01/29/24 10:10:00)  Rapid Influenza A PCR: Not Detected (01/29/24 10:10:00)  Rapid Influenza B PCR: Not Detected (01/29/24 10:10:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 01/29/2024 06:03 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  Wall thickening and pericolonic fat stranding involving therectum, and to a lesser degree the distal sigmoid colon, concerningfor rectosigmoid colitis. This could be infectious or inflammatory.2.  There is a small extraluminal air and fluid collection measuringapproximately 2.1 x 1.0 cm in greatest axial dimension andapproximately 0.8 cm in greatest CC dimension. This is concerning fora small extraluminal abscess.3.  There is an approximately 4.5 x 4.1 x 5.2 cm left ovarian cyst,which was also present in 2022. This could be recurrent or residualcyst.Thank you for consulting our team of subspecialty radiologists at Physicians Radiology. Please contact us  with any questions.    01/29/2024 06:03 - CT Head W/o IV Contrast  IMPRESSION: 1.  No acute CT abnormality of the head. No acute intracranialhemorrhage or hydrocephalus.-Thank you for consulting our team of subspecialty radiologists at Physicians Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 01/29/24 11:57  ________________________________________________________  NP     Addendum by MD on January 29, 2024 14:04:41  (Verified)    I saw and evaluated the patient in addition to NP. I provided a substantive portion of the care for this patient. I personally performed in its entirety the history, exam and medical decision making for this encounter. I have reviewed and verified this documentation and it accurately reflects our care.  Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Breathing comfortably on room air Cardiovascular:  Regular rate and rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect   MD, FACP   Signature Line Electronically Signed on 01/29/24 14:04  ________________________________________________________ MD     Addendum by on January 29, 2024 16:11:41  (Verified)    OBGYN and GI consult pending   Signature Line Electronically Signed on 01/29/24 16:12  ________________________________________________________  NP     Addendum by NP on January 29, 2024 16:12:48 (Verified)    WIll need to f/u outpatient for ovarian cyst as an outpatient.  OBGYN is out for the next week.   Signature Line Electronically Signed on 01/29/24 16:14  ________________________________________________________  NP