Age: 83.0
Sex: F
Vaccine: VARZOS
Symptoms: Abdominal pain, Abdominal tenderness, Acute kidney injury, Alanine aminotransferase normal, Anaemia
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on January 20, 2025 13:46    Verified By: MD on January 20, 2025 13:46    Encounter Info: Hospital, Inpatient, 01/20/25 -     * Final Report *        Chief Complaint   Diarrhea  History of Present Illness/Subjective     Patient is an 83 year old woman who presents to the ER w/ diarrhea and abd pain for the last 3 days. Patient endorses watery diarrhea, no blood. She has also had abd pain and increased urinary frequency. She denies any fever. Upon arrival to the ER she was tachycardic and afebrile. BP was 91/60. Labs were notable for a WBC count of 12. Hgb was 11. Na was 129 and Cr was 2.6. CT abd/pelvis showed e/o colitis. Lactate was 2.3 but repeat was normal. Patient was given fluids and admitted to the medicine service for further management.     Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective Vitals & Measurements most recent past 24 hours       Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  CTAB Cardiovascular:  Regular rate and rhythm, no MGR Gastrointestinal:  non-distended, tender to palpation Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan      1. Colitis   K52.9  -Unclear cause  -GIP panel  -GI consult  -Zosyn      2. AKI (acute kidney injury)   N17.9  -Pre-renal in nature  -LR at 100cc/hr  -PVR urine  -Renally dose meds      3. Dehydration   E86.0  -Fluids as above      4. Hyponatremia   E87.1  -The patient presents with a electrolyte imbalance including hypo-osmolality and hyponatremia.  Continue to trend serial analysis as appropriate with replenishment of electrolyte imbalance as required for stabilization.  -Hypovolemic  -Fluids as above      5. Anemia   D64.9  -The patient presents with anemia chronic and normocytic due to other chronic disease at present is stable.  Continue to trend serial analysis as appropriate with nutritional or blood product supplementation as required.      6. Leukocytosis   D72.829  -Non-specific finding  -Likely due to colitis      7. GERD (gastroesophageal reflux disease)   K21.9  -Continue PPI      8. Hyperlipidemia   E78.5  -Continue statin        Code Status  Full Code   Chronic Problem List    Acute respiratory failure  Anemia  Cervical radiculopathy  CKD (chronic kidney disease), stage II  COPD (chronic obstructive pulmonary disease)  COPD bronchitis  COVID  DDD (degenerative disc disease), cervical  DDD (degenerative disc disease), lumbar  GERD (gastroesophageal reflux disease)  Goiter  Hematuria  History of peptic ulcer  Hyperlipidemia  Hypoalbuminemia  Long term use of drug  Lumbar radiculopathy  Lung nodule  Osteoarthritis  Osteopenia  PE (pulmonary thromboembolism)  Pneumonia  Postmenopausal  Reactive thrombocytosis  Smoking  Thrombocytosis  UTI (urinary tract infection)  Procedure/Surgical History  ?Back surgery (07/17/2024) ?colonoscopy (05/15/2014) ?small bowel capsule (04/29/2014) ?egd (04/24/2014) ?back surgery (05/2010) ?abdominal laparotomy multiple times ?c-section ?cataract removal with lens implants ?goiter removed from neck ?hysterectomy ?lumbar surgery ?rotator cuff repair right shoulder   Surgical History Internal  06/17/2024    Spine Fusion Posterior Lumbar  (Postr)   MD  04/02/2018    Spine Fusion Posterior Lumbar     MD  03/07/2016    Lumbar Laminectomy  (Left)   MD  Medications   Home Medications (10) Active  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q6H, COPD  atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, QHS  DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed.  DULOXetine 30 mg oral delayed release capsule 30 mg = 1 Capsule, Orally, Daily, TAKE 1 CAPSULE BY MOUTH DAILY  gabapentin 100 mg oral capsule 100 mg = 1 Capsule, Orally, 4 Times Daily  hydroxyurea 500 mg oral capsule 1 Capsule, Orally, Daily  Magic Potion oral solution 5 mL, Orally, 4 Times Daily, Swish and Spit  montelukast 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  OXYcodone-acetaminophen 7.5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q4H  pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily  Active Scheduled Inpatient Medications  Sodium Chloride 0.9% 500 mL IV Continuous 42 mL/hr Days 1, 8       One-Time Medications Given 01/19/25 00:00:00 TO 01/20/25 13:41:14  None Reported  PRN Medications (0600 - 0559) from 01/19 - 01/20  None Reported  Allergies   Eggs (Blisters)  No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse, 35YR OLD GRANDSON.   Nutrition/Health   Diet: Regular.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago. Started age 16.0 Years. Stopped age 83 Years.  Family History   Breast cancer: Mother.  Cancer of colon: Daughter.  Diabetes mellitus type 2: Mother.  Heart attack..: Mother.  Prostate cancer..: Father.   Deceased Family Member(s)  Relationship: Mother, Age: Unknown, Cause: DM, CA of breast, heart  Relationship: Father, Age: Unknown, Cause: Bladder CA, Prostate CA then to Bone  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 12 k/cumm High (01/20/25 08:08:00)  RBC: 3.24 million/cumm Low (01/20/25 08:08:00)  Hgb: 11.8 GM/dL Low (01/20/25 08:08:00)  Hct: 35.6 % (01/20/25 08:08:00)  MCV: 110 fL High (01/20/25 08:08:00)  MCH: 36.5 pg High (01/20/25 08:08:00)  MCHC: 33.2 GM/dL (01/20/25 08:08:00)  RDW: 24.1 % High (01/20/25 08:08:00)  Platelet: 212 k/cumm (01/20/25 08:08:00)  MPV: 8.5 fL (01/20/25 08:08:00)  Neutrophils %: 94 % (01/20/25 08:08:00)  Lymphocytes %: 3 % (01/20/25 08:08:00)  Monocytes %: 3 % (01/20/25 08:08:00)  Eosinophils %: 0 % (01/20/25 08:08:00)  Basophils %: 0 % (01/20/25 08:08:00)  Absolute Neutrophil: 11.3 k/cumm High (01/20/25 08:08:00)  Absolute Lymphocyte: 0.4 k/cumm Low (01/20/25 08:08:00)  Absolute Monocyte: 0.4 k/cumm (01/20/25 08:08:00)  Absolute Eosinophil: 0 k/cumm (01/20/25 08:08:00)  Absolute Basophil: 0 k/cumm (01/20/25 08:08:00)  Chemistry:  Sodium SerPl QN: 129 mmol/L Low (01/20/25 08:08:00)  Potassium SerPl QN: 5.5 mmol/L (01/20/25 08:08:00)  Chloride SerPl QN: 95 mmol/L Low (01/20/25 08:08:00)  Carbon Dioxide SerPl QN: 25 mmol/L (01/20/25 08:08:00)  Anion Gap: 9 mmol/L (01/20/25 08:08:00)  BUN SerPl QN: 60 mg/dL High (01/20/25 08:08:00)  Creatinine SerPl QN: 2.63 mg/dL High (01/20/25 08:08:00)  Estimated GFR (CKD-EPI, no race): 18 mL/min/1.73m2 Low (01/20/25 08:08:00)  Estimated CRCL (CG): 9 mL/min Low (01/20/25 08:08:00)  Glucose SerPl QN: 175 mg/dL High (01/20/25 08:08:00)  Calcium Total SerPl QN: 7.4 mg/dL Low (01/20/25 08:08:00)  Alkaline Phos SerPl QN: 92 Units/L (01/20/25 08:08:00)  ALT SerPl QN: 15 Units/L (01/20/25 08:08:00)  AST SerPl QN: 47 Units/L High (01/20/25 08:08:00)  Bilirubin Direct SerPl QN: <0.1 (01/20/25 08:08:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (01/20/25 08:08:00)  Total Protein SerPl QN: 5.1 GM/dL Low (01/20/25 08:08:00)  Albumin SerPl QN: 2.5 GM/dL Low (01/20/25 08:08:00)  Magnesium SerPl QN: 1.8 mg/dL (01/20/25 08:08:00)  Lipase SerPl QN: 4 Units/L Low (01/20/25 08:08:00)  Lactate Venous Pl QN: 1.4 mmol/L (01/20/25 11:09:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (01/20/25 08:29:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (01/20/25 08:29:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (01/20/25 08:29:00)  Rapid Influenza A PCR: Not Detected (01/20/25 08:29:00)  Rapid Influenza B PCR: Not Detected (01/20/25 08:29:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 01/20/2025 09:17 - CT Abd/Pelvis W/O IV Contrast  IMPRESSION: 1.  Status post cholecystectomy and hysterectomy and probablyprevious hiatal hernia repair.2.  Mild ascites.3.  Bilateral nonobstructing nephrolithiasis.4.  Diffuse wall thickening of the colon and rectum consistent withcolitis.             Signature Line Electronically Signed on 01/20/25 13:46  ________________________________________________________  MD