Age: 65.0
Sex: M
Vaccine: MMRV
Symptoms: Urine analysis abnormal, Urine ketone body present, Urine leukocyte esterase, Urobilinogen urine, White blood cell count increased
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: May 02, 2023 16:39   Verified By: May 02, 2023 23:42  Encounter Info: Emergency, 05/02/23 - 05/03/23    * Final Report *        Basic Information  Time Seen: 05/02/2023 16:34  Chief Complaint  Abdominal Pain   History of Present Illness     65 year old male with past medical history of chronic hypoxemic respiratory failure, COPD on 4L O2, HTN, BPH, GERD, OSA on CPAP, cholecystitis, morbid obesity presents to the ED with complaint of generalized abdominal pain/distention onset today. Reports last BM was this morning, it was normal, and then 2nd BM today was loose stools. He reports nausea without vomiting as well. Denies fevers, chills, cough, or other acute  Patient has HX of hernia s/p repair in LLQ. His appendix and gallbladder are present. States he has been told that he needs to have cholecystectomy, but this has not been performed. Additionally, last year, patient was admitted to the hospital for SBO and abdominal wall hernia. Patient notes that he recently received a MMR vaccination 2 days ago on Sunday at the clinic. States he received immunizations when he was young, but not in adulthood, and has been told he needs pneumonia vaccinations among others. Reports he has received COVID vaccination x2.  Review of Systems     Constitutional:  No fevers Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No sore throat Respiratory:  No shortness of breath,  no cough Cardiovascular:  No chest pain,  no edema Gastrointestinal:  + Abdominal pain,  + nausea,  no vomiting,  + diarrhea Genitourinary:  No dysuria,  no hematuria Musculoskeletal:  No arthralgia,  no myalgia Skin:  No rash Neurologic:  No headache,  no focal weakness Additional ROS info:  Except as noted in the above Review of Systems and in the History of Present Illness, all other systems have been reviewed and are negative or noncontributory.  Physical Exam/Objective  Vitals & Measurements most recent  T: 36.6 °C (Temporal Artery)  BP: 123/83  HR: 100 (Peripheral)  RR: 20  SpO2: 91%  Oxygen Therapy: Nasal Cannula  Oxygen Flow Rate: 4 (L/min)  WT: 143.20 kg  HT: 172.6 cm      Constitutional:  Alert,no acute distress,  morbid obestiy Head:  No trauma, normocephalic Eyes:  PEERL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosaTM clear with normal light reflex, Nares patent without discharge, Normal oral pharynx and tonsils without erythema, exudate or edema Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTA, respirations non-labored symmetric expansion Cardiovascular:  Regular rate and rhythm, normalperipheral perfusion Gastrointestinal:  Abdomen is significant distended, tenderness to percussion of the LLQ, hyperresonant on palpation, No rebound, No guarding Musculoskeletal:  No joint swelling, no deformity, no trauma, intact ROM Integumentary:  Intact, warm, dry, no rashes Neurologic: Neurological:  Oriented x4  , LOC appropriate for age, CNII-XII intact, motor strength equal and normal bilaterally, sensation equal and normal bilaterally  , speech normal Psychiatric:  Cooperative ,  appropriate for ageaffect  , normal  judgement,  normal psychiatric thoughts  Medical Decision Making     RN note reviewed  Vitals reviewed  Previous records reviewed  Labs: reviewed  Diagnostics: reviewed  EKG: reviewed by myself and Dr.  DDx includes but is not limited to: SBO    Performed chart reviewed discharge summary note from 04/19/22. Patient was admitted to the hospital 04/14/22 with a SBO and abdominal wall hernia. He did not undergo surgery, they opted for conservative management due to his severe COPD.  Additionally, patient was diagnosed with acute cholecystitis in 07/2022, which was also managed conservatively due to patient's COPD.  05/02/23 19:29:42   Discussed with Radiology who reports that pts CT abd/pelvis shows partial bowel obstruction. No high grade transition point but there are dilated bowel loops.  05/02/23 20:25:22  Discussed with Dr., Hospitalist, who thinks that pt can be admitted here as soon as a bed is available.   Radiologist called to say CT shows incomplete SBO. NG tube ordered. 10:31 pm No NG tube in place. CT printed final reading states no abd pelvis abnormality. Radiologist called to request explanation on normal report.          Condition     Stable.      Assessment/Plan     Endorsed to Dr at the end of my shift. NG tube in place Dx partial SBO      Follow Up  No qualifying data available   Chronic Problem List    Abdominal hernia  BPH (benign prostatic hyperplasia)  Chronic hypoxemic respiratory failure  GERD (gastroesophageal reflux disease)  Hypertension  Morbid obesity  OSA on CPAP  Rib sprain  Procedure/Surgical History  ?Lt leg repair torn ligaments (1992) ?groin  Surgical History Internal  07/21/2017    CT Drain  07/10/2017    Rib Fixation  (Left)  Medications  Home Medications (11) Active albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, Neb Inhal, Q6H aspirin 81 mg, Orally, Daily Breo Ellipta 100 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed. Flomax 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily Kal Potassium 99 oral tablet 99 mg = 1 Tablet, Orally, Daily Lasix 80 mg oral tablet 80 mg = 1 Tablet, Orally, BID multivitamin 1 Tablet, Orally, Daily omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, Daily Ventolin HFA 90 mCg/inh inhalation aerosol 90 mCg = 1 Puff, PRN, Inhalation, 4 Times Daily    Allergies   Bee Stings (Anaphylaxis)  No Known Medication Allergies  Social History    Alcohol   Past   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.    Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  05/02/23 18:28  11.3  High  07/26/22  23.1  High          RBC  05/02/23 18:28  6.38  High  07/26/22  5.24          Hgb  05/02/23 18:28  15.9  07/26/22  14.8          Hct  05/02/23 18:28  50.4  07/26/22  45.6          MCV  05/02/23 18:28  79  Low  07/26/22  87          MCH  05/02/23 18:28  25.0  Low  07/26/22  28.2          MCHC  05/02/23 18:28  31.6  Low  07/26/22  32.4          RDW  05/02/23 18:28  18.9  High  07/26/22  16.1  High          Platelet  05/02/23 18:28  224  07/26/22  234          MPV  05/02/23 18:28  10.0  07/26/22  8.7          Neutrophils %  05/02/23 18:28  81  04/19/22  75          Lymphocytes %  05/02/23 18:28  11  04/19/22  15          Monocytes %  05/02/23 18:28  7  04/19/22  9          Eosinophils %  05/02/23 18:28  0  04/19/22  1          Basophils %  05/02/23 18:28  0  04/19/22  0          Absolute Neutrophil  05/02/23 18:28  9.2  High  04/19/22  6.4          Absolute Lymphocyte  05/02/23 18:28  1.2  04/19/22  1.3          Absolute Monocyte  05/02/23 18:28  0.8  04/19/22  0.8          Absolute Eosinophil  05/02/23 18:28  0.0  04/19/22  0.1          Absolute Basophil  05/02/23 18:28  0.0  04/19/22  0.0          Routine Coagulation Studies FS  LATEST RESULTS        PT  05/02/23 17:31  12.6        INR  05/02/23 17:31  1.10           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  05/02/23 17:31  133  Low  07/26/22  131  Low          Potassium SerPl QN  05/02/23 17:31  4.2  07/26/22  4.5          Chloride SerPl QN  05/02/23 17:31  96  Low  07/26/22  94  Low          Carbon Dioxide SerPl QN  05/02/23 17:31  27  07/26/22  27          Anion Gap  05/02/23 17:31  10  07/26/22  10          BUN SerPl QN  05/02/23 17:31  9  07/26/22  17          Creatinine SerPl QN  05/02/23 17:31  0.95  07/26/22  1.24          Estimated GFR (CKD-EPI, no race)  05/02/23 17:31  89  07/26/22  65          Estimated CRCL (CG)  05/02/23 17:31  108  07/26/22  86          Glucose SerPl QN  05/02/23 17:31  91  07/26/22  112  High          Calcium Total SerPl QN  05/02/23 17:31  9.4  07/26/22  9.6          Alkaline Phos SerPl QN  05/02/23 17:31  65  07/26/22  71          ALT SerPl QN  05/02/23 17:31  6  Low  07/26/22  11          AST SerPl QN  05/02/23 17:31  23  07/26/22  15          Bilirubin Total SerPl QN  05/02/23 17:31  1.6  High  07/26/22  2.7  High          Total Protein SerPl QN  05/02/23 17:31  9.1  High  07/26/22  8.3  High          Albumin SerPl QN  05/02/23 17:31  3.9  07/26/22  3.6          Lipase SerPl QN  05/02/23 17:31  34  07/26/22  18           Urinalysis FS  LATEST RESULTS  HISTORICAL RESULTS          Color  05/02/23 17:05  Light-Yellow  07/26/22  Yellow          Clarity  05/02/23 17:05  Clear  07/26/22  Clear          Specific Gravity  05/02/23 17:05  1.008  07/26/22  1.010          pH  05/02/23 17:05  7.5  07/26/22  8.0          Protein  05/02/23 17:05  Negative  07/26/22  30 Abnormal          Glucose  05/02/23 17:05  Normal  07/26/22  Negative          Ketones  05/02/23 17:05  10 Abnormal  07/26/22  15 Abnormal          Bilirubin  05/02/23 17:05  Negative  07/26/22  See Comment Abnormal          Hgb Ur  05/02/23 17:05  Negative  07/26/22  Negative          Nitrite  05/02/23 17:05  Negative  07/26/22  Negative          Urobilinogen  05/02/23 17:05  Normal  07/26/22  2.0 Abnormal          Leukocyte Esterase Ur  05/02/23 17:05  Negative  07/26/22  Negative          WBC  05/02/23 17:05  0-5  07/26/22  0-5          RBC  05/02/23 17:05  0-2  07/26/22  0-2          Bacteria  05/02/23 17:05  None  07/26/22  Trace          Squamous Epithelial  05/02/23 17:05  Few  07/26/22  Few           Molecular Diagnostic Tests  LATEST RESULTS  HISTORICAL RESULTS          COVID 19 Specimen Source  05/02/23 17:31  Nasopharyngeal  07/26/22  Nasopharyngeal          Coronavirus SARS-CoV2 Rapid  05/02/23 17:31  Not Detected  07/26/22  Not Detected            Signature Line Electronically Signed on 05/02/23 17:04 ________________________________________________________   Electronically Signed on 05/02/23 21:17 ________________________________________________________   Electronically Signed on 05/02/23 23:42