Age: 63.0
Sex: F
Vaccine: FLU3
Symptoms: Monocyte count normal, Monocyte percentage, Neutrophil count normal, Neutrophil percentage increased, Nitrite urine absent
Clinical narrative: Document Type: Internal Medicine IP Progress Note   Document Subject: Progress Note Comprehensive   Performed By: MD on October 10, 2024 11:21 EDT   Verified By: MD on October 10, 2024 11:21 EDT   Encounter Info: Inpatient, 10/09/24 -     * Final Report *  Document Contains Addenda        Subjective     This note was dictated using Dictation. If any errors with dictation, please contact me via diagnotes for clarification.   f/u acute diverticulitis   Assuming care from Dr.   Nothing acute overnight.  Vital signs appear to be stable.  No leukocytosis this morning.  H&H is stable.  AKI appears to be improving.  Electrolytes are stable.  LFTs stable.  Currently on Zosyn.  General surgery consulted this morning.   Seen and examined this morning.  No acute complaints.  She did seem more somnolent during my evaluation but also just received pain medications.  Nursing and case manager report that she had been conversant with them.  Advised nursing to obtain a VBG and placed on end-tidal CO2 monitoring.???????  Review of Systems     per HPI???????  Objective  Vitals and Measurements  Vitals & Measurements most recent past 24 hours  T: 37.7 °C (Route Not Specified)  TMIN: 36.7 °C (Oral)  TMAX: 37.8 °C (Oral)  BP: 172/66  HR: 102 (Monitored)  RR: 20  SpO2: 92%  Oxygen Therapy: Room air  Oxygen Flow Rate: 0 (L/min)  WT: 112.3 kg  BMI: 43.1    Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    112.3 kg    10/10/24  Previous Daily Weight:    112.3 kg    10/10/24  BMI:    43.1    10/10/24    Morbid Obesity (BMI > = 40) Patient Height  Current Height:    161 cm    10/10/24      Intake/Output  I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 10/09 - 10/10  Total Intake 4578.68 mL    Total Output 0.00 mL     Balance 4578.68 mL     Physical Exam     Constitutional:  No acute distress Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Skin:  Intact, warm, dry no rashes Neurologic:  Somnolent during my evaluation???????  Assessment/Plan       1. Acute diverticulitis   K57.92    2. Constipation   K59.00    3. Leukocytosis   D72.829  Problems 1-3:   Zosyn on admission -- > Changed to Rocephin/Flagyl on 10/10/24??????? per my discussion w/ EGS  C/w IVF  Surgery consulted  (10/09/2024 23:08 EDT CT Abd/Pelvis W/IV Contrast) IMPRESSION: 1. Circumferential wall thickening of the sigmoid colon with diverticuli. There is an extraluminal collection of gas and inflamed fat at the level of the mid sigmoid colon, concerning for area of contained perforation/phlegmon. This measures approximately 1.5 x 4.6 cm. There is no drainable fluid in this area. There is loss of fat planes between the inferior sigmoid colon and the superior urinary bladder wall, with circumferential wall thickening of the urinary bladder. There is no gas in the urinary bladder. Overall, findings are concerning for a perforated diverticulitis. Consider possibility of developing colovesicular fistula. Recommend follow-up colonoscopy after resolution of acute symptoms to exclude underlying malignancy. 2. Markedly distended gallbladder with a small amount of stones and/or sludge. There is mild intrahepatic and extrahepatic biliary ductal dilatation. Findings may be due to fasting state. Correlate with liver function tests. 3. Large stool burden throughout the colon. 4. Small hiatal hernia. 5. Tiny, 2 mm noncalcified pulmonary nodule in the right lower lobe. If the patient is high-risk, consider short-term interval follow-up in one years' time. [1]  (10/09/2024 16:52 EDT XR Abdomen KUB) IMPRESSION: 1. Moderate stool burden throughout the colon. [2]   4. Acute on chronic renal insufficiency   N28.9  C/w IVF  Cr trending down   5. Depression   F32.9  C/w routine management    6. GERD (gastroesophageal reflux disease)   K21.9  C/w routine management    7. Chronic narcotic use   F11.90  Noted    8. Hyperlipidemia   E78.5  C/w routine management    9. Hypertension   I10  Will titrate meds accordingly   10. Hypothyroid   E03.9  TSH Last 3 TSH 3rd Gen SerPl QN: 4.905 mcU/mL High (07/05/24)  C/w routine management     11. OSA on CPAP   G47.33  C/w RT protocol   DVT ppx: SubQ Heparin  Code: FULL   Dispo:   CBC, BMP, LFT's, Lipid pnl reviewed  CT and KUB reviewed  Surgery consulted  Discussed w/ case management  Meds reconciled???????  Continue hospital management of acute perf diverticulitis which can pose a threat to life/bodily function     Orders:   ceftRIAXone, 1 GM, IV Push, Injection, Q24H, Reason for Use: Intra-Abdominal Infection, 10/10/24 12:00:00 EDT  metroNIDAZOLE, 500 mg, Orally, Tablet, TID, Reason for Use: Intra-Abdominal Infection, 10/10/24 15:00:00 EDT  Blood Gas Venous QN  End Tidal CO2 Monitor Continuous  OT Evaluation and Treatment  PT Evaluation and Treatment   Code Status  Resuscitation Status - Ordered    -- 10/10/24 2:03:00 EDT, Full Code   Medications   Active Scheduled Inpatient Medications  aripiprazole, Tablet, 2.5 mg, Orally, QAM, Start: 10/10/24 09:00:00  aspirin, Tab, Delayed Rel, 81 mg, Orally, BID, Start: 10/10/24 09:00:00  atorvastatin, Tablet, 80 mg, Orally, QAM, Start: 10/10/24 09:00:00  ceftRIAXone, Injection, 1 GM, IV Push, Q24H, Indication: Intra-Abdominal Infection, Start: 10/10/24 12:00:00  docusate (Colace), Capsule, 100 mg, Orally, BID, Start: 10/10/24 09:00:00  famotidine, Tablet, 10 mg, Orally, Daily, Start: 10/10/24 09:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 10/10/24 03:00:00  hydrALAZINE, Tablet, 50 mg, Orally, TID, Start: 10/10/24 09:00:00  lactobacillus acidophilus and bulgaricus (lactobacillus acidophilus and bulgaricus oral tablet, chewable), Tab, Chewable, 1 Tablet, Orally, Daily, Start: 10/10/24 09:00:00  levothyroxine, Tablet, 25 mCg, Orally, QAM, Start: 10/10/24 06:00:00  metroNIDAZOLE (Flagyl), Tablet, 500 mg, Orally, TID, Indication: Intra-Abdominal Infection, Start: 10/10/24 15:00:00  miconazole topical (miconazole 2% topical powder), Powder, 1 App, Topical, BID, Start: 10/10/24 09:00:00  pantoprazole, Tab, Delayed Rel, 40 mg, Orally, BID, Start: 10/10/24 09:00:00  sertraline, Tablet, 100 mg, Orally, QAM, Start: 10/10/24 09:00:00  tiZANidine, Tablet, 8 mg, Orally, BID, Start: 10/10/24 09:00:00  traMADOL, Tablet, 50 mg, Orally, BID, Start: 10/10/24 09:00:00  traZODONE, Tablet, 50 mg, Orally, At Bedtime, Start: 10/10/24 21:00:00  Sodium Chloride 0.9%  1,000 mL IV Continuous  100 mL/hr 0  10/10/24  Sodium Chloride 0.9%  500 mL IV Continuous  Other - See Comments     Sodium Chloride 0.9%  250 mL IV Continuous  Other - See Comments       One-Time Medications Given 10/09/24 00:00:00 TO 10/10/24 11:21:16  acetaminophen (Tylenol), Tablet, 1,000 mg, Orally, ONCE, (1 DOSE 10/09/24 23:17:00)  HYDROmorphone (HYDROmorphone Inj ED (1 mg/mL)), Injection, 0.5 mg, IV Push, ONCE, (1 DOSE 10/09/24 16:24:00)  HYDROmorphone (Dilaudid), Injection, 0.5 mg, IV Push, ONCE, (1 DOSE 10/10/24 04:37:00)  magnesium citrate, Oral SOLN, 300 mL, Orally, ONCE, (1 DOSE 10/09/24 18:40:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 10/09/24 16:24:00)  piperacillin-tazobactam (Zosyn), Injection, 4.5 GM, IV Push, ONCE, (1 DOSE 10/10/24 00:45:00)  Phenergan, Injection, 25 mg, IVPB, ONCE, (1 DOSE 10/09/24 23:17:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 10/09/24 16:20:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 10/09/24 17:14:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 10/09/24 18:39:00)  PRN Medications (0600 - 0559) from 10/09 - 10/10  OXYcodone-acetaminophen, 1 Tablet, Orally, Q4H, 0  Dose(s)   acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   albuterol, Inhalation, Q6H, 0  Dose(s)   morphine, 2 mg, IV Push, Q2H, 1  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 0  Dose(s)   Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.2 k/cumm (10/10/24 07:23:00)  RBC: 4.25 million/cumm (10/10/24 07:23:00)  Hgb: 11.1 GM/dL Low (10/10/24 07:23:00)  Hct: 34.7 % Low (10/10/24 07:23:00)  MCV: 82 fL (10/10/24 07:23:00)  MCH: 26.2 pg Low (10/10/24 07:23:00)  MCHC: 32.1 GM/dL (10/10/24 07:23:00)  RDW: 14.9 % High (10/10/24 07:23:00)  Platelet: 327 k/cumm (10/10/24 07:23:00)  MPV: 9.5 fL (10/10/24 07:23:00)  Neutrophils %: 86 % (10/10/24 07:23:00)  Lymphocytes %: 10 % (10/10/24 07:23:00)  Monocytes %: 4 % (10/10/24 07:23:00)  Eosinophils %: 0 % (10/10/24 07:23:00)  Basophils %: 1 % (10/10/24 07:23:00)  Absolute Neutrophil: 7.9 k/cumm High (10/10/24 07:23:00)  Absolute Lymphocyte: 0.9 k/cumm Low (10/10/24 07:23:00)  Absolute Monocyte: 0.4 k/cumm (10/10/24 07:23:00)  Absolute Eosinophil: 0 k/cumm (10/10/24 07:23:00)  Absolute Basophil: 0.1 k/cumm (10/10/24 07:23:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (10/10/24 07:23:00)  Potassium SerPl QN: 3.9 mmol/L (10/10/24 07:23:00)  Chloride SerPl QN: 107 mmol/L (10/10/24 07:23:00)  Carbon Dioxide SerPl QN: 21 mmol/L Low (10/10/24 07:23:00)  Anion Gap: 11 mmol/L (10/10/24 07:23:00)  BUN SerPl QN: 23 mg/dL High (10/10/24 07:23:00)  Creatinine SerPl QN: 1.78 mg/dL High (10/10/24 07:23:00)  Estimated GFR (CKD-EPI, no race): 32 mL/min/1.73m2 Low (10/10/24 07:23:00)  Estimated CRCL (CG): 38 mL/min Low (10/10/24 07:23:00)  Glucose SerPl QN: 102 mg/dL High (10/10/24 07:23:00)  Calcium Total SerPl QN: 9.8 mg/dL (10/10/24 07:23:00)  Alkaline Phos SerPl QN: 144 Units/L High (10/10/24 07:23:00)  ALT SerPl QN: 19 Units/L (10/10/24 07:23:00)  AST SerPl QN: 36 Units/L (10/10/24 07:23:00)  Bilirubin Total SerPl QN: 0.7 mg/dL (10/10/24 07:23:00)  Total Protein SerPl QN: 7.2 GM/dL (10/10/24 07:23:00)  Albumin SerPl QN: 3.6 GM/dL (10/10/24 07:23:00)  Magnesium SerPl QN: 1.7 mg/dL (10/10/24 07:23:00)  Cholesterol SerPl QN: 129 mg/dL (10/10/24 07:23:00)  Triglyceride SerPl QN: 74 mg/dL (10/10/24 07:23:00)  HDL SerPl QN: 37 mg/dL Low (10/10/24 07:23:00)  LDL Calculated QN: 77 mg/dL (10/10/24 07:23:00)  Total Chol/HDL Ratio: 3 (10/10/24 07:23:00)  Lactate Venous Pl QN: 0.8 mmol/L (10/09/24 16:19:00)  TSH 3rd Gen SerPl QN: 0.939 mcU/mL (10/10/24 07:23:00)  Urine Studies:  Color: Yellow (10/09/24 16:33:00)  Clarity: Clear (10/09/24 16:33:00)  Specific Gravity: 1.023 (10/09/24 16:33:00)  pH: 5.5 (10/09/24 16:33:00)  Protein: 50 Abnormal (10/09/24 16:33:00)  Glucose: Normal (10/09/24 16:33:00)  Ketones: NEGATIVE (10/09/24 16:33:00)  Bilirubin: NEGATIVE (10/09/24 16:33:00)  Hgb Ur: NEGATIVE (10/09/24 16:33:00)  Nitrite: NEGATIVE (10/09/24 16:33:00)  Urobilinogen: 4.0 4 Abnormal (10/09/24 16:33:00)  Leukocyte Esterase Ur: Small75 Abnormal (10/09/24 16:33:00)  WBC: 6-10 Abnormal (10/09/24 16:33:00)  RBC: 3-5 Abnormal (10/09/24 16:33:00)  Bacteria: NONE (10/09/24 16:33:00)  Squamous Epithelial: Few (10/09/24 16:33:00)  Hyaline Casts: 11-20 (10/09/24 16:33:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 10/09/2024 16:52 - XR Abdomen KUB  IMPRESSION:1.  Moderate stool burden throughout the colon. Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at (redacted) with any questions.    10/09/2024 23:08 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  Circumferential wall thickening of the sigmoid colon withdiverticuli. There is an extraluminal collection of gas and inflamedfat at the level of the mid sigmoid colon, concerning for area ofcontained perforation/phlegmon. This measures approximately 1.5 x 4.6cm. There is no drainable fluid in this area. There is loss of fatplanes between the inferior sigmoid colon and the superior urinarybladder wall, with circumferential wall thickening of the urinarybladder. There is no gas in the urinary bladder. Overall, findingsare concerning for a perforated diverticulitis. Consider possibilityof developing colovesicular fistula. Recommend follow-up colonoscopyafter resolution of acute symptoms to exclude underlying malignancy.2.  Markedly distended gallbladder with a small amount of stonesand/or sludge. There is mild intrahepatic and extrahepatic biliaryductal dilatation. Findings may be due to fasting state. Correlatewith liver function tests.3.  Large stool burden throughout the colon.4.  Small hiatal hernia.5.  Tiny, 2 mm noncalcified pulmonary nodule in the right lower lobe.If the patient is high-risk, consider short-term interval follow-upin one years' time.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at (redacted) with any questions.               [1] CT Abd/Pelvis W/IV Contrast; MD 10/09/2024 23:08 EDT  [2] XR Abdomen KUB;MD 10/09/2024 16:52 EDT   Signature Line Electronically Signed on 10/10/24 11:21 EDT ________________________________________________________ MD     Addendum by MD on October 10, 2024 14:10:38 EDT (Verified)    Advising RT to re-engage with regards to CPAP/BIPAP. D'c all pain meds except Oxy which I have spaced out to q8h for now.   Signature Line Electronically Signed on 10/10/24 14:11 EDT ________________________________________________________ MD