Age: 50.0
Sex: M
Vaccine: COVID19
Symptoms: Haemoglobin normal, Haemoglobin urine present, Hernia repair, Intestinal dilatation, Intussusception
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: October 06, 2022 16:23 EDT   Verified By: October 06, 2022 18:38 EDT   Encounter Info: Hospital, Emergency, 10/06/22 - 10/06/22    * Final Report *        Basic Information  Time Seen:  10/06/2022 16:18  Chief Complaint  Abdominal pain (Complaint of)  History of Present Illness     51 year old male presents to the ED via private vehicle complaining of lower abdominal pain onset approx. 1100. He also reports diarrhea for the past two weeks. 4-5 BMs per day. Patient notes that he had back pain last week, but this has since resolved. Denies n/v. Patient expresses fear that he is experiencing lactic acidosis as a result of taking Metformin. HE started Metformin in January 2022. SHx includes double hernia repair. Denies hx of kidney stones.  Review of Systems     Constitutional: no fever   Skin: No jaundice Eye: no recent vision problems ENT: no ear pain Respiratory: no hemoptysis Cardiovascular: no chest pain Gastrointestinal: + abdominal pain, +diarrhea Genitourinary: no dysuria Back: no back pain, no joint pain Neurologic: no headache Heme/Lymph: no bruising Additional ROS info:   Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.4 DegC  Heart Rate:       66 bpm  Resp Rate:       18 br/min  BP #1:       129 / 80 mmHg  SpO2 (%):       99 %     Height CM: 175.3 cm  Weight KG: 67.7 kg  Ideal Body Weight: 70.74 kg     Constitutional:  alert,   Skin: warmdry Head: normocephalic Eyes:  EOMI ENMT:  Moist oral mucosa Neck: Supple Respiratory:  Lungs CTArespirations non-laboredbreath sounds equal Cardiovascular:  Regular rate and rhythmno edemanormal peripheral perfusion Chest Wall: no tenderness Back: normal ROM Gastrointestinal:  Soft,non-tender, non-distended, normal BS Musculoskeletal:  No swelling, no deformity Neurologic: A & O x4,  no focal neuro deficitsnormal sensorynormal motornormal speech Psychiatric: Cooperative  Medical Decision Making     Chart Review: ED RN notes, prior records  Labs: Reviewed Diagnostic imaging: _  I have transitioned care of the patient to Dr. we have discussed the clinical presentation, work-up, and ED course thus far.              Condition     Stable Disposition: 10/06/22 18:02:21 Transitioned care         I Dr. attest that the scribe's documentation has been prepared under my direction and personally reviewed by me in it's entirety.  I confirm that the note above accurately reflects all work, treatment, procedures, and medical decision making performed by me.       Assessment/Plan       1. Abdominal pain   R10.9    2. Diarrhea   R19.7    3. Mesenteric lymphadenopathy   R59.0    Orders:   Auto Diff  CBC w/Differential  Comp Metabolic Panel  CT Abd/Pelvis W/IV Contrast  Lactate Pl Venous QN  Lipase SerPl QN  Peripheral IV Insertion  UA Microscopic  Urinalysis w Culture Rflx  XR Chest PA or AP     Follow Up  No qualifying data available   Chronic Problem List    No qualifying data      Medications  No qualifying data available    Allergies   penicillin      Lab Results      Hemogram-Platelets-WBC Differential FS  LATEST RESULTS        WBC  10/06/22 16:25  8.2        RBC  10/06/22 16:25  4.75        Hgb  10/06/22 16:25  14.8        Hct  10/06/22 16:25  44.1        MCV  10/06/22 16:25  93        MCH  10/06/22 16:25  31.1        MCHC  10/06/22 16:25  33.5        RDW  10/06/22 16:25  16.3  High        Platelet  10/06/22 16:25  356        MPV  10/06/22 16:25  8.2        Neutrophils %  10/06/22 16:25  67        Lymphocytes %  10/06/22 16:25  21        Monocytes %  10/06/22 16:25  10        Eosinophils %  10/06/22 16:25  1        Basophils %  10/06/22 16:25  1        Absolute Neutrophil  10/06/22 16:25  5.5        Absolute Lymphocyte  10/06/22 16:25  1.7        Absolute Monocyte  10/06/22 16:25  0.8        Absolute Eosinophil  10/06/22 16:25  0.1        Absolute Basophil  10/06/22 16:25  0.1          Routine Chemistry Tests FS  LATEST RESULTS        Sodium SerPl QN  10/06/22 16:25  138        Potassium SerPl QN  10/06/22 16:25  3.7        Chloride SerPl QN  10/06/22 16:25  103        Carbon Dioxide SerPl QN  10/06/22 16:25  27        Anion Gap  10/06/22 16:25  8        BUN SerPl QN  10/06/22 16:25  6        Creatinine SerPl QN  10/06/22 16:25  0.86        Estimated GFR (CKD-EPI)  10/06/22 16:25  >90        Estimated GFR (CKD-EPI, no race)  10/06/22 16:25  >90        Estimated CRCL (CG)  10/06/22 16:25  97        Glucose SerPl QN  10/06/22 16:25  98        Calcium Total SerPl QN  10/06/22 16:25  8.6        Alkaline Phos SerPl QN  10/06/22 16:25  57        ALT SerPl QN  10/06/22 16:25  23        AST SerPl QN  10/06/22 16:25  27        Bilirubin Total SerPl QN  10/06/22 16:25  0.6        Total Protein SerPl QN  10/06/22 16:25  6.0  Low        Albumin SerPl QN  10/06/22 16:25  3.7        Lipase SerPl QN  10/06/22 16:25  4  Low        Lactate Venous Pl QN  10/06/22 16:25  0.8          Urinalysis FS  LATEST RESULTS        Color  10/06/22 16:25  Yellow        Clarity  10/06/22 16:25  Clear        Specific Gravity  10/06/22 16:25  1.010        pH  10/06/22 16:25  5.5        Protein  10/06/22 16:25  Negative        Glucose  10/06/22 16:25  Negative        Ketones  10/06/22 16:25  Negative        Bilirubin  10/06/22 16:25  Negative        Hgb Ur  10/06/22 16:25  Trace Abnormal        Nitrite  10/06/22 16:25  Negative        Urobilinogen  10/06/22 16:25  Normal        Leukocyte Esterase Ur  10/06/22 16:25  Negative        WBC  10/06/22 16:25  0-5        RBC  10/06/22 16:25  0-2        Bacteria  10/06/22 16:25  Few Abnormal        Squamous Epithelial  10/06/22 16:25  Few        Mucous  10/06/22 16:25  Present      Diagnostic Results  No qualifying data available.        Signature Line Electronically Signed on 10/06/22 16:55 EDT ________________________________________________________   Electronically Signed on 10/06/22 18:04 EDT ________________________________________________________   Electronically Signed on 10/06/22 18:38 EDT ________________________________________________________   Electronically Signed on 10/07/22 00:57 EDT ________________________________________________________