Age: 59.0
Sex: F
Vaccine: COVID19
Symptoms: Urine leukocyte esterase, Urobilinogen urine decreased, Viral infection, Vomiting, White blood cell count increased
Clinical narrative: Document Type: ED Physician Progress Note, Document Subject: ED Progress Note. Chief Complaint abdominal pain  History of Present Illness     Time Seen: 10/29/21 11:07:21 HPI: 60 year old year old female with hx of  HLD, HTN and Microalbuminuria presents to the ED via private vehicle c/o abdominal pain onset 2 weeks ago. Pt states that other symptoms have subsided, however abdominal pain has persisted throughout. Pt localizes pain to the epigastrium. Pt notes previous symptoms of fever, nausea, emesis and diarrhea that had been intermittently ongoing, but is now resolved. Pt has taken Pepto- Bismol.  Review of Systems     Gastrointestinal: +epigastric pain Additional review of symptoms:  Except as noted above in the HPI and the ROS, all systems are otherwise negative or noncontributory     Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.2 DegC  Heart Rate:       68 bpm  Resp Rate:       20 br/min  BP #1:       188 / 77 mmHg  SpO2 (%):       97 %  O2 Device:       room air     Height CM: 154.9 cm  Weight KG: 102.5 kg  Ideal Body Weight: 47.76 kg     General: moderate distress Skin: Warm, dry Head: Normocephalic Eyes: PEERL, EOMI, normal conjunctiva ENMT:  oral mucosa moist, no pharyngeal erythema or exudate Neck: Supple, trachea midline, no tenderness Cardiovascular: Regular rate and rhythm, no murmur, normal peripheral perfusion Respiratory: Lungs clear to auscultation, non-labored respirations, breath sounds equal, symmetrical expansion Chest wall: No tenderness, no deformity, Gastrointestinal: Soft, epigastric tenderness, non-distended, obese Back: Nontender Musculoskeletal: no tenderness Neurological: Alert and oriented to person, place, time, and situation, no focal neurological deficits, normal motor, normal speech, normal coordination Psychiatric: Cooperative, appropriate mood and affect  Medical Decision Making  Charts reviewed: ED RN notes  EKG: none obtained  Labs: reviewed  Diagnostic Imaging: none obtained  Re-Assessment  10/29/21 12:21:43 Reassessed pt at bedside. Discussed imaging results with patient, which  were unremarkable at this time. Counselled patient that based off symptomatic presentation, provided HPI, and physical exam findings, onset of symptoms are . Will give  pantoprazole and sucralfate for  treatment. Discussed patients plan for discharge. Informed patient to return to the ED for new or worsening symptoms for further evaluation. Patient should follow up with PCP.  Patient understands and agrees to plan. All questions addressed.    Prescriptions:       pantoprazole 40 mg, = 1 Tablet, Orally, Daily, Maintenance, Dispense: 30 Tablet, Refills: 0, Total Refills: 0, 10/29/21 12:29:00 EDT, Pharmacy, 1 Tablet Orally Daily, Supply, 154.9, cm, 10/29/21 11:08:00 EDT, Height CM, 102.5, kg, 10/29/21 11:1...       sucralfate 1 GM, 10 mL, Orally, BID, Maintenance, Dispense: 200 mL, Refills: 0, Total Refills: 1, 10/29/21 12:28:00 EDT, Pharmacy:, 10 mL Orally BID,x10 Days, 154.9, cm, 10/29/21 11:08:00 EDT, Height CM, 102.5, kg, 10/29/21 11:11:00 EDT, Weigh...     Condition     stable  Disposition: 10/29/21 12:26:13 discharged  counseled: Patient, discussed diagnosis,  diagnostic studies, prescriptions, follow up plan and strict return to the ED instructions, all additional questions answered.    I, attest that the scribes documentation has been prepared under my direction in person and by me in its entirety.  I confirm that the note above accurately reflects all the work, treatment, procedures, and medical decision-making performed by me.  Assessment/Plan       1. Abdominal pain, epigastric   R10.13    Orders:   pantoprazole, 40 mg, = 1 Tablet, Orally, Daily, Maintenance, Dispense: 30 Tablet, Refills: 0, Total Refills: 0, 10/29/21 12:29:00 EDT, Pharmacy, 1 Tablet Orally Daily, Supply, 154.9, cm, 10/29/21 11:08:00 EDT, Height CM, 102.5, kg, 10/29/21 11:1...  sucralfate, 1 GM, 10 mL, Orally, BID, Maintenance, Dispense: 200 mL, Refills: 0, Total Refills: 1, 10/29/21 12:28:00 EDT, Pharmacy, 10 mL Orally BID,x10 Days, 154.9, cm, 10/29/21 11:08:00 EDT, Height CM, 102.5, kg, 10/29/21 11:11:00 EDT, Weigh...  Auto Diff  CBC w/Differential  Comp Metabolic Panel  Discharge Patient  Lipase SerPl QN  Peripheral IV Insertion  UA Microscopic  Urinalysis   Patient Education   Gastritis (Adult)  Epigastric Pain (Uncertain Cause) (DHOLBROOK)  Follow Up        With  When  Contact Information  Additional Instructions:  Chronic Problem List    B12 deficiency  Depression  Hyperlipidemia  Hypertension  Long term use of drug  Long-term insulin use  Microalbuminuria  Morbid obesity  PTSD (post-traumatic stress disorder)  Type 2 diabetes mellitus with renal manifestations  Procedure/Surgical History  ?Mammogram (05/01/2018) ?colonoscopy (08/05/2015) ?D&C - Dilatation and curettage ?History of appendectomy ?History of total hysterectomy with bilateral salpingo-oophorectomy (BSO). ?ovary cyst removed  Medications  Home Medications (21) Active acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q6H amitriptyline 10 mg oral tablet 10 mg = 1 Tablet, Orally, At Bedtime, 1-2 tab at night aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily BD Ultra-Fine Short (8mm x 31G) Pen Needle See Instructions, Use 1 time daily Breeze 2 Test Strips Check up to 2 times daily, Other, Unscheduled, testing before breakfast and 2hrs after eating carvedilol 12.5 mg oral tablet 12.5 mg = 1 Tablet, Orally, BID, Take with the 6.25mg bid carvedilol 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, BID, take with 12.5 mg BID hydroCHLOROthiazide 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily Klor-Con oral tablet, extended release See Instructions, TAKE 1 TABLET EVERY DAY Lexapro 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily lovastatin 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily metFORMIN 1000 mg oral tablet See Instructions, TAKE 1 TABLET BY MOUTH TWICE A DAY WITH MEALS NovOLIN 70/30 (insulin NPH-insulin regular) subcutaneous injection 45 Units, Subcutaneous, BID ondansetron 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q8H promethazine 25 mg rectal suppository 25 mg = 1 Suppository, PRN, Rectally, Q6H Syringes - Insulin 1 mL See Instructions, Use to inject insulin twice daily.DX: E11.65, Z79.4. 31 g. use as directed with insulin See Instructions, Subcutaneous BID verapamil 360 mg/24 hours oral capsule, extended release 360 mg = 1 Capsule, Orally, Daily verapamil 360 mg/24 hours oral capsule, extended release 360 mg = 1 Capsule, Orally, Daily Victoza 18 mg/3 mL subcutaneous solution 0.6 mg, Subcutaneous, Daily Zetia 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Medication Administration   Given  fentaNYL, 50 mCg, IV Push  ondansetron, 8 mg, IV Push  Sodium Chloride 0.9% - ED Bolus, 1000 mL, IVPB  Allergies   Adhesive Bandage (rash)  Aleve (md stated neurological issue)  Contrast Dye  Dilaudid (breating issues)  Red Dye (critical)  Tape (rash)  codeine  ibuprofen (neurological issue)  lisinopril (critical)  morphine (can't recall reaction)  penicillins (critical)  Social History    Alcohol   Denies   Substance Abuse   Denies   Tobacco   Tobacco Use: Former Smoker. Stopped age 40 Years. Second-hand smoke info requested: No.  Family History   Afib..: Mother.  Diabetes mellitus type 2: Mother, Father and Brother.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  10/29/21 11:25  10.3  10/20/21  10.5          RBC  10/29/21 11:25  4.64  10/20/21  4.95          Hgb  10/29/21 11:25  13.6  10/20/21  14.7          Hct  10/29/21 11:25  40.8  10/20/21  43.5          MCV  10/29/21 11:25  88  10/20/21  88          MCH  10/29/21 11:25  29.2  10/20/21  29.7          MCHC  10/29/21 11:25  33.2  10/20/21  33.8          RDW  10/29/21 11:25  14.8  High  10/20/21  15.3  High          Platelet  10/29/21 11:25  267  10/20/21  261          MPV  10/29/21 11:25  8.8  10/20/21  8.9          Neutrophils %  10/29/21 11:25  69  10/20/21  75          Lymphocytes %  10/29/21 11:25  22  10/20/21  18          Monocytes %  10/29/21 11:25  6  10/20/21  6          Eosinophils %  10/29/21 11:25  2  10/20/21  0          Basophils %  10/29/21 11:25  1  10/20/21  1          Absolute Neutrophil  10/29/21 11:25  7.1  10/20/21  7.9  High          Absolute Lymphocyte  10/29/21 11:25  2.2  10/20/21  1.9          Absolute Monocyte  10/29/21 11:25  0.6  10/20/21  0.6          Absolute Eosinophil  10/29/21 11:25  0.2  10/20/21  0.0          Absolute Basophil  10/29/21 11:25  0.1  10/20/21  0.1           Routine Serum/Plasma Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  10/29/21 11:25  139  10/20/21  139          Potassium SerPl QN  10/29/21 11:25  3.2  Low  10/20/21  3.1  Low          Chloride SerPl QN  10/29/21 11:25  99  10/20/21  96  Low          Carbon Dioxide SerPl QN  10/29/21 11:25  30  High  10/20/21  27          Anion Gap  10/29/21 11:25  10  10/20/21  16  High          BUN SerPl QN  10/29/21 11:25  15  10/20/21  20          Creatinine SerPl QN  10/29/21 11:25  0.75  10/20/21  0.95          Estimated GFR (CKD-EPI)  10/29/21 11:25  87  10/20/21  65          Estimated CRCL (CG)  10/29/21 11:25  88  10/20/21  70          Glucose SerPl QN  10/29/21 11:25  197  High  10/20/21  201  High          Calcium Total SerPl QN  10/29/21 11:25  9.3  10/20/21  9.7          Alkaline Phos SerPl QN  10/29/21 11:25  53  10/20/21  51          ALT SerPl QN  10/29/21 11:25  10  10/20/21  10          AST SerPl QN  10/29/21 11:25  9  Low  10/20/21  16          Bilirubin Total SerPl QN  10/29/21 11:25  0.3  10/20/21  0.7          Total Protein SerPl QN  10/29/21 11:25  6.6  10/20/21  7.5          Albumin SerPl QN  10/29/21 11:25  3.8  10/20/21  4.2          Lipase SerPl QN  10/29/21 11:25  32              Urinalysis FS  LATEST RESULTS        Color  10/29/21 11:25  Yellow        Clarity  10/29/21 11:25  Clear        Specific Gravity  10/29/21 11:25  >=1.030        pH  10/29/21 11:25  5.5        Protein  10/29/21 11:25  30 Abnormal        Glucose  10/29/21 11:25  Negative        Ketones  10/29/21 11:25  Trace Abnormal        Bilirubin  10/29/21 11:25  See Comment Abnormal        Hgb Ur  10/29/21 11:25  Trace Abnormal        Nitrite  10/29/21 11:25  Negative        Urobilinogen  10/29/21 11:25  Normal        Leukocyte Esterase Ur  10/29/21 11:25  Negative        WBC  10/29/21 11:25  None Seen        RBC  10/29/21 11:25  3-5 Abnormal        Bacteria  10/29/21 11:25  Moderate Abnormal        Squamous Epithelial  10/29/21 11:25  Few      Diagnostic Results  No qualifying data available.           Document Type: ED Physician Progress Note  * Final Report *     Chief Complaint  Vomiting/ Fever  History of Present Illness     The Pt is a 60 yo female who presents w/ 3 days of vomiting, malaise, subjective fevers, sore throat and sob.  She has chronic chest and back pain.  She denies diarrhea or abd pain.  She is fully vaccinated against COVID.  She reports not taking her insulin since she hasn't been feeling good and not eating much.  No other complaints.  Review of Systems     Constitutional:  + Fever,  no chills Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No sore throat Respiratory:  + Shortness of breath,  no cough Cardiovascular:  No chest pain,  no edema Gastrointestinal:  No 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 last 24 hours  VITAL SIGNS  Temp C:       37.9 DegC  Heart Rate:       73 bpm  Resp Rate:       20 br/min  BP #1:       169 / 72 mmHg  SpO2 (%):       95 %  O2 Device:       Room air     Height CM: 154.9 cm  Weight KG: 104.5 kg  Ideal Body Weight: 47.76 kg      Constitutional:  + Mild distress,  well-nourished, ill appearing but non-toxic Eyes:  PEERL,  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               Re-Assessment  Pt feeling better but still nauseated.  Gave another dose of zoran, and will send home w/ the same and phenergan suppositories.  CXR shows possible mild basilar disease, and compared to prior in 2016, not much change.  Ketones neg, increased gap but no acidosis on VBG.  Plan:   1.  Your COVID test result is pending; blood cultures are pending  2.  Take the nausea medication scheduled for the first 24 hrs, then as needed thereafter (don't wait to get nauseated)  3.  Drink clear liquids, gatorade, bland foods; avoid spicy/fatty foods  4.  F/u with your PCM or the nearest ED if your symptoms worsen  All questions answered, return precautions given and the Pt v/u.  Condition     Stable  Assessment/Plan       1. Viral syndrome   B34.9    Orders:   ondansetron, 4 mg, = 1 Tablet, Orally, Q8H, PRN for nausea and vomiting, Maintenance, Dispense: 20 Tablet, Refills: 0, Total Refills: 1, 10/20/21 5:20:00 EDT, Pharmacy, 1 Tablet Orally Q8H,PRN:for nausea and vomiting, 154.9, cm, 10/20/21 1:33:0...  promethazine, 25 mg, = 1 Suppository, Rectally, Q6H, PRN for nausea/vomiting, Maintenance, Dispense: 12 Suppository, Refills: 0, Total Refills: 1, 10/20/21 5:20:00 EDT, Pharmacy, 1 Suppository Rectally Q6H,PRN:for nausea/vomiting, 154.9, cm, 10/...  Sodium Chloride 0.9%, 1,000 mL, IVPB, Infusion, Unscheduled, PRN, Other-See Comments, 10/20/21 1:54:00 EDT, 1000 mL/hr, Infuse Over 60 Minutes, Total Volume (mL) = 1,000  Auto Diff  Blood CX  Blood CX  Blood Gas Venous QN  Cardiac Monitor  CBC w/Differential  Comp Metabolic Panel  Continuous Oxygen Saturation  Discharge Patient  Electrocardiogram  Ketones SerPl QN  Lactate Pl Venous QN  Peripheral IV Insertion  Sepsis Tracking  Troponin-I High Sensitivity  Urinalysis w Culture Rflx  XR Chest PA or AP Portable   Patient Education   Viral Syndrome (Adult)  Follow Up        With  When  Contact Information        Follow up with a provider of your choice Within 3 to 5 days       Additional Instructions:          Chronic Problem List    B12 deficiency  Depression  Hyperlipidemia  Hypertension  Long term use of drug  Long-term insulin use  Microalbuminuria  Morbid obesity  PTSD (post-traumatic stress disorder)  Type 2 diabetes mellitus with renal manifestations  Procedure/Surgical History  ?Mammogram (05/01/2018) ?colonoscopy (08/05/2015) ?D&C - Dilatation and curettage ?History of appendectomy ?History of total hysterectomy with bilateral salpingo-oophorectomy (BSO). ?ovary cyst removed  Medications  Home Medications (21) Active acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q6H amitriptyline 10 mg oral tablet 10 mg = 1 Tablet, Orally, At Bedtime, 1-2 tab at night aspirin 81 mg oral tablet 81 mg = 1 Tablet, Orally, Daily BD Ultra-Fine Short (8mm x 31G) Pen Needle See Instructions, Use 1 time daily Breeze 2 Test Strips Check up to 2 times daily, Other, Unscheduled, testing before breakfast and 2hrs after eating carvedilol 12.5 mg oral tablet 12.5 mg = 1 Tablet, Orally, BID, Take with the 6.25mg bid carvedilol 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, BID, take with 12.5 mg BID hydroCHLOROthiazide 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily Klor-Con oral tablet, extended release See Instructions, TAKE 1 TABLET EVERY DAY Lexapro 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily lovastatin 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily metFORMIN 1000 mg oral tablet See Instructions, TAKE 1 TABLET BY MOUTH TWICE A DAY WITH MEALS NovOLIN 70/30 (insulin NPH-insulin regular) subcutaneous injection 45 Units, Subcutaneous, BID ondansetron 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q8H promethazine 25 mg rectal suppository 25 mg = 1 Suppository, PRN, Rectally, Q6H Syringes - Insulin 1 mL See Instructions, Use to inject insulin twice daily.DX: E11.65, Z79.4. 31 g. use as directed with insulin See Instructions, Subcutaneous BID verapamil 360 mg/24 hours oral capsule, extended release 360 mg = 1 Capsule, Orally, Daily verapamil 360 mg/24 hours oral capsule, extended release 360 mg = 1 Capsule, Orally, Daily Victoza 18 mg/3 mL subcutaneous solution 0.6 mg, Subcutaneous, Daily Zetia 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Medication Administration   Given  ondansetron, 8 mg, IV Push  ondansetron, 4 mg, IV Push  potassium chloride extended release, 60 mEq, Orally  Sodium Chloride 0.9% Bolus, 1432.8 mL, IVPB  Allergies   Adhesive Bandage (rash)  Aleve (md stated neurological issue)  Contrast Dye  Dilaudid (breating issues)  Red Dye (critical)  Tape (rash)  codeine  ibuprofen (neurological issue)  lisinopril (critical)  morphine (can't recall reaction)  penicillins (critical)  Social History    Alcohol   Denies   Substance Abuse   Denies   Tobacco   Tobacco Use: Former Smoker. Stopped age 40 Years. Second-hand smoke info requested: No.  Family History   Afib..: Mother.  Diabetes mellitus type 2: Mother, Father and Brother.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  10/20/21 01:54  10.5   07/30/21  8.4          RBC  10/20/21 01:54  4.95   07/30/21  4.67          Hgb  10/20/21 01:54  14.7   07/30/21  13.4          Hct  10/20/21 01:54  43.5   07/30/21  41.2          MCV  10/20/21 01:54  88   07/30/21  88          MCH  10/20/21 01:54  29.7   07/30/21  28.8          MCHC  10/20/21 01:54  33.8   07/30/21  32.6          RDW  10/20/21 01:54   15.3  High   07/30/21  14.1          Platelet  10/20/21 01:54  261   07/30/21  275          MPV  10/20/21 01:54  8.9   07/30/21  9.1          Neutrophils %  10/20/21 01:54  75   07/30/21  67          Lymphocytes %  10/20/21 01:54  18   07/30/21  25          Monocytes %  10/20/21 01:54  6   07/30/21  6          Eosinophils %  10/20/21 01:54  0   07/30/21  2          Basophils %  10/20/21 01:54  1   07/30/21  1          Absolute Neutrophil  10/20/21 01:54   7.9  High   07/30/21  5.6          Absolute Lymphocyte  10/20/21 01:54  1.9   07/30/21  2.1          Absolute Monocyte  10/20/21 01:54  0.6   07/30/21  0.5          Absolute Eosinophil  10/20/21 01:54  0.0   07/30/21  0.2          Absolute Basophil  10/20/21 01:54  0.1   07/30/21  0.1              Routine Serum/Plasma Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  10/20/21 02:03  139   07/30/21  140          Potassium SerPl QN  10/20/21 02:03   3.1  Low   07/30/21  3.9          Chloride SerPl QN  10/20/21 02:03   96  Low   07/30/21  102          Carbon Dioxide SerPl QN  10/20/21 02:03  27   07/30/21  28          Anion Gap  10/20/21 02:03   16  High   07/30/21  10          BUN SerPl QN  10/20/21 02:03  20   07/30/21   23  High          Creatinine SerPl QN  10/20/21 02:03  0.95   07/30/21  0.92          Estimated GFR (CKD-EPI)  10/20/21 02:03  65   07/30/21  68          Estimated CRCL (CG)  10/20/21 02:03  70   07/30/21  71          Glucose SerPl QN  10/20/21 02:03   201  High   07/30/21   239  High          Gluc-Strip, POC  10/20/21 01:39   193  High              Calcium Total SerPl QN  10/20/21 02:03  9.7   07/30/21  9.3          Alkaline Phos SerPl QN  10/20/21 02:03  51   07/30/21  55          ALT SerPl QN  10/20/21 02:03  10   07/30/21  11          AST SerPl QN  10/20/21 02:03  16   07/30/21   8  Low          Bilirubin Total SerPl QN  10/20/21 02:03  0.7   07/30/21  0.4          Total Protein SerPl QN  10/20/21 02:03  7.5   07/30/21  6.6          Albumin SerPl QN  10/20/21 02:03  4.2   07/30/21  3.8          Troponin-I High Sensitivity  10/20/21 02:03   19  High              Ketones SerPl QN  10/20/21 01:55  Negative              Lactate Venous Pl QN  10/20/21 02:03  1.3                 Blood Gases FS  LATEST RESULTS        pH Bld Venous QN  10/20/21 01:54   7.53  High        PCO2 Bld Venous QN  10/20/21 01:54   36  Low        PO2 Bld Venous QN  10/20/21 01:54   <34  Low        Base Excess Bld Venous  10/20/21 01:54   7  High        Bicarb Bld Venous Calc  10/20/21 01:54   30  High        O2 Sat Bld Venous Calc  10/20/21 01:54  72        Patient Temperature  10/20/21 01:54  37.0      Diagnostic Results  XR Chest PA or AP Portable    10/20/21 02:48:41  IMPRESSION:  Minimal right base airspace disease versus atelectasis.