Age: 87.0
Sex: F
Vaccine: COVID19-2
Symptoms: Urine analysis abnormal, Urine ketone body present, Urine leukocyte esterase, Urobilinogen urine, White blood cell count increased
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on February 04, 2023 23:49 EST   Verified By: MD on February 04, 2023 23:49 EST   Encounter Info: Hospital, Inpatient, 02/04/23 -     * Final Report *        Chief Complaint   Leg redness  History of Present Illness/Subjective     Pleasant 87-year-old female with past medical history including asthma, GERD, hypertension, osteoarthritis, here with leg swelling and redness.   The patient describes swelling of the left lower extremity for the last 2 weeks.  She has been worked up with outpatient studies including negative Doppler and negative age-adjusted D-dimer.  No evidence of DVT.  White blood cell count is normal with normal differential.  Afebrile.  Today, the leg started developing erythema, light pinkish in color, started over the left pretibial region rapidly progressing to include the foot to the mid thigh region, irregular border, no clear-cut open wound, ulceration, etc.  She is not diabetic.  She is on no immune modulating medications.   Left lower extremity swelling, mildly painful, x2 weeks, no relieving or exacerbating factors, no recent antibiotics, developing erythema today over the shin and rapidly progressing over the foot and mid thigh region, at this time no pain and not tender, denies associated fever and chills     Review of Systems     Remaining 10 point review of systems negative except as noted above  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.7 (36.7-36.7)  Temp (FAHR) 98.1 (98.1-98.1), BP 123/66 (123-123)/(66-66), HR 107 (107-107), RR 20 (20-20)     Patient Weight  Current Daily Weight:    104.0 kg    02/04/23    Patient Height        Constitutional:  No acute distress,  well-nourished see vital signs, nontoxic Eyes:  PERRLA,   normal conjunctiva ENMT:  Moist oral mucosa Neck:  Supple, non-tender, Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, intact ROM, there does not appear to be any erythema or swelling specific to the knee or ankle joints Integumentary:  Intact, warm, dry.  There is light pink/salmon-colored erythema of the left lower extremity extending from the foot to the mid thigh region, irregular margins, no ulceration, no fluctuance, no open wound or drainage.  No crepitus.  The extremity is edematous but not tense at all.  Lymphatics: No obvious lymphangitic spread, no inguinal lymphadenopathy noted Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan       Asthma   J45.909  Stable, home meds   Cellulitis of left lower extremity   L03.116  Nonpurulent.  Does not meet SIRS criteria.  Appearance more suggestive of Streptococcus source, however, given rapid progression, will cover broadly including clindamycin for toxin mediation.  Cultures obtained.  Monitor for signs of worsening infection, necrotizing infection, etc.   Chronic GERD   K21.9  Home meds   History of mitral valve prolapse   Z86.79    Hypertension   I10  Home meds   Osteoarthritis   M19.90  I see no gross inflammatory change about the knee.  Monitor clinically   Orders:   metoPROLOL, 50 mg, = 1 Tablet, Orally, At Bedtime, Maintenance, Dispense: 90 Tablet, Refills: 3, Total Refills: 3, 11/16/22 6:54:00 EST, Pharmacy: MAILSERVICE Pharmacy, 167.65, cm, 09/21/22 18:04:00 EDT, Height CM, 104.2, kg, 08/25/22 8:09:00 EDT, We...  Full code.  Lovenox for DVT prophylaxis.  Code Status  FULL CODE   Chronic Problem List    Asthma  Cervical disc disease  Cervical radiculopathy  Chronic GERD  DJD (degenerative joint disease) of knee  Frozen shoulder  History of mitral valve prolapse  Hyperglycemia  Hyperlipidemia  Hypertension  Immunization due  Impingement syndrome of shoulder region  Long-term use of high-risk medication  Lumbar disc disease  Lumbar disc disease with radiculopathy  Obstructive sleep apnea on CPAP  Osteoarthritis  Ovarian cyst, follicular  Seasonal allergies  Vitamin B12 deficiency  Procedure/Surgical History  ?Colonoscopy (11/03/2017) ?Mammogram (10/10/2014) ?Total knee replacement (03/18/1998) ?Carpal tunnel surgery ?Cataract extraction ?Cholecystectomy ?Fissure repair ?Foraminotomy ?Hip prosthesis ?Surgery on achilles tendon   Surgical History Internal  11/03/2017    Colonscpy Diagnostic/Screen    MD  10/29/2007    Eye Muscle Repair  (Right)   MD  Medications   Home Medications (16) Active  aspirin 81 mg, Orally, Daily  biotin 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily  Calcium 600+D 1 Tablet, Orally, Daily  gabapentin 100 mg oral capsule 200 mg = 2 Capsule, Orally, At Bedtime  hydroCODONE-acetaminophen 5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q4  Lasix 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  latanoprost ophthalmic 1 Drop, Eyes, Both, At Bedtime  Maxzide 25 mg-37.5 mg oral tablet 1 Tablet, Orally, Daily  metoPROLOL succinate 50 mg oral tablet, extended release 50 mg = 1 Tablet, Orally, At Bedtime  MiraLax 17 GM, Orally, Daily  multivitamin , Orally, Daily  Naprosyn 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID  omeprazole 20 mg oral delayed release capsule 20 mg = 1 Capsule, Orally, Daily  Potassium Chloride (Eqv-K-Tab) 20 mEq oral tablet, extended release 20 mEq = 1 Tablet, Orally, BID  Senna , Orally, Daily, 2 tablets  Timoptic Ocudose , Eyes, Both, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 02/03/23 00:00:00 TO 02/04/23 23:49:17  None Reported  PRN Medications (0600 - 0559) from 02/03 - 02/04  None Reported  Allergies   tetracycline (mucous membrane swelling)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Employed, Work/School description: RN.   Home/Environment   G1P1   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Cancer of colon: Father and Sister.  Heart attack..: Brother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 13.5 k/cumm High (02/04/23 17:33:00)  RBC: 4.88 million/cumm (02/04/23 17:33:00)  Hgb: 14.5 GM/dL (02/04/23 17:33:00)  Hct: 44.3 % (02/04/23 17:33:00)  MCV: 91 fL (02/04/23 17:33:00)  MCH: 29.7 pg (02/04/23 17:33:00)  MCHC: 32.7 GM/dL (02/04/23 17:33:00)  RDW: 13.9 % (02/04/23 17:33:00)  Platelet: 207 k/cumm (02/04/23 17:33:00)  MPV: 9 fL (02/04/23 17:33:00)  Neutrophils %: 71 % (02/04/23 17:33:00)  Lymphocytes %: 16 % (02/04/23 17:33:00)  Monocytes %: 11 % (02/04/23 17:33:00)  Eosinophils %: 1 % (02/04/23 17:33:00)  Basophils %: 0 % (02/04/23 17:33:00)  Absolute Neutrophil: 9.6 k/cumm High (02/04/23 17:33:00)  Absolute Lymphocyte: 2.1 k/cumm (02/04/23 17:33:00)  Absolute Monocyte: 1.5 k/cumm High (02/04/23 17:33:00)  Absolute Eosinophil: 0.1 k/cumm (02/04/23 17:33:00)  Absolute Basophil: 0.1 k/cumm (02/04/23 17:33:00)  Chemistry:  Sodium SerPl QN: 137 mmol/L (02/04/23 17:33:00)  Potassium SerPl QN: 3.7 mmol/L (02/04/23 17:33:00)  Chloride SerPl QN: 98 mmol/L (02/04/23 17:33:00)  Carbon Dioxide SerPl QN: 29 mmol/L (02/04/23 17:33:00)  Anion Gap: 10 mmol/L (02/04/23 17:33:00)  BUN SerPl QN: 22 mg/dL High (02/04/23 17:33:00)  Creatinine SerPl QN: 0.85 mg/dL (02/04/23 17:33:00)  Estimated GFR (CKD-EPI, no race): 66 mL/min/1.73m2 (02/04/23 17:33:00)  Estimated CRCL (CG): 56 mL/min Low (02/04/23 17:33:00)  Glucose SerPl QN: 94 mg/dL (02/04/23 17:33:00)  Calcium Total SerPl QN: 10.2 mg/dL (02/04/23 17:33:00)  Alkaline Phos SerPl QN: 103 Units/L (02/04/23 17:33:00)  ALT SerPl QN: 12 Units/L (02/04/23 17:33:00)  AST SerPl QN: 17 Units/L (02/04/23 17:33:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (02/04/23 17:33:00)  Total Protein SerPl QN: 7 GM/dL (02/04/23 17:33:00)  Albumin SerPl QN: 4 GM/dL (02/04/23 17:33:00)  Lactate Venous Pl QN: 0.7 mmol/L (02/04/23 17:33:00)  Urine Studies:  Color: Yellow (02/04/23 18:45:00)  Clarity: Clear (02/04/23 18:45:00)  Specific Gravity: <=1.005 (02/04/23 18:45:00)  pH: 6.5 (02/04/23 18:45:00)  Protein: NEGATIVE (02/04/23 18:45:00)  Glucose: NEGATIVE (02/04/23 18:45:00)  Ketones: TRACE. Abnormal (02/04/23 18:45:00)  Bilirubin: NEGATIVE (02/04/23 18:45:00)  Hgb Ur: NEGATIVE (02/04/23 18:45:00)  Nitrite: NEGATIVE (02/04/23 18:45:00)  Urobilinogen: NormalUro (02/04/23 18:45:00)  Leukocyte Esterase Ur: NEGATIVE (02/04/23 18:45:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (02/04/23 18:45:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (02/04/23 18:45:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 02/04/2023 18:53 - XR Chest PA or AP  IMPRESSION: No acute findings in the chest.Thank you for consulting our team of subspecialty emergencyradiologists at radiology.Healthcare providers wishing to discuss this case further can contactthe  Radiology reading room.                Signature Line Electronically Signed on 02/04/23 23:49 EST ________________________________________________________ MD