Age: 55.0
Sex: F
Vaccine: COVID19
Symptoms: Splenic granuloma, Suprapubic pain, Urinary sediment present, Urine analysis, Urine analysis abnormal
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on October 07, 2022 18:46   Verified By: MD on October 07, 2022 22:28   Encounter Info: Hospital, Emergency, 10/07/22 - 10/07/22    * Final Report *        Basic Information  Time Seen: MD / 10/07/2022 18:43  Chief Complaint  right side pain  History of Present Illness     Pt seen: 10/07/22 18:45:27 A 56 year old female presents to the ED via private vehicle c/o right sided suprapubic pain. Pt states that her has ben experiencing this pain for the past month with worsening recently. She describes her pain as excruciating, constant, and is exacerbated by movement. Her husband notes she often lifts heavy luggage bags for work. She has not taken any medications for her pain.  Pt denies nausea, vomiting, fevers, dysuria, or hematuria.  Review of Systems     Constitutional: No fevers Gastrointestinal: + right sided suprapubic pain, no vomiting, no nausea Genitourinary: No dysuria, no hematuria Additional review of systems information: All other systems reviewed and otherwise negative.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.4 DegC  Heart Rate:       68 bpm  Resp Rate:       18 br/min  BP #1:       162 / 85 mmHg  SpO2 (%):       100 %  O2 Device:       Room air     Weight KG: 97.6 kg     General: Alert, no acute distress Head: Normocephalic, atraumatic Eyes: Pupils equal, round, and reactive to light, extraocular movements are intact Cardiovascular: Regular rate and rhythm, no murmur Respiratory: non-labored respirations Gastrointestinal: right sided mid abdominal tenderness, no palpable hernia, Soft, non-distended Musculoskeletal: Normal range of motion Neurological: Alert and oriented to person, place, time, and situation, no focal neurological deficits Psychological: Cooperative, appropriate mood & affect  Medical Decision Making      Vital signs, nursing charting and past history reviewed as pertinent to the case.  I have reviewed all studies ordered by myself and any relevant comparisons.  Rationale:  Differential diagnosis includes but not limited to: muscular skeletal cause, vs psychosomatic cause, vs less likely malignancy, less likely hernia   Will get labs and abdominal CT and give pain medication.   Likely disposition: Discharge.  10/07/22 21:41:37: Labs are unremarkable. Will have pt follow up with Dr., GI, for findings of unknown significance on her CT scan.  10/07/22 21:42:48  Reassessment: Pt is well appearing and in no distress. Vitals stable.. Updated pt on all diagnostic results.  Discussed plan for discharge with GI follow up. Counseled the patient regarding return precautions for new or worsening symptoms, as discussed. The patient is comfortable with the plan for discharge. All questions addressed.      Condition     Stable Disposition: 10/07/22 21:43:03   Discharged home Counseled: Patient, regarding diagnosis, regarding diagnostic studies, regarding treatment plan. Patient indicated understanding of instructions.   Scribe Attestation  I, acting as a scribe for Dr. on 10/07/22 18:45:54. Signed, 10/07/22 18:45:54.  I, MD, have reviewed this note and attest to its contents.  It was prepared under my direction and at the time of my signature I will have reviewed it in its entirety and edited where appropriate.  Assessment/Plan       1. Abdominal pain   R10.9     Patient Education   PCP Follow Up (CUSTOM)  Abdominal Pain  Follow Up        With  When  Contact Information        MD, SUR Within 1 to 2 weeks Additional Instructions: Call for appointment           Follow up with primary care provider Within 1 to 2 weeks       Additional Instructions:          Chronic Problem List    Pain in finger of left hand  Procedure/Surgical History  ?Fracture ?Trauma    Medications  Home Medications (2) Active azithromycin 500 mg oral tablet 500 mg = 1 Tablet, Orally, Daily Tylenol   Medication Administration   Given  ketoROLAC, 15 mg, IV Push  Allergies   Keflex  azithromycin (gagging)  Social History    Alcohol   Denies   Tobacco   Tobacco Use: Never Smoker.    Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  10/07/22 19:29  8.3  05/13/21  7.7          RBC  10/07/22 19:29  4.84  05/13/21  5.25  High          Hgb  10/07/22 19:29  13.9  05/13/21  15.5  High          Hct  10/07/22 19:29  42.0  05/13/21  45.3          MCV  10/07/22 19:29  87  05/13/21  86          MCH  10/07/22 19:29  28.7  05/13/21  29.5          MCHC  10/07/22 19:29  33.1  05/13/21  34.3          RDW  10/07/22 19:29  13.3  05/13/21  12.5          Platelet  10/07/22 19:29  189  05/13/21  191          MPV  10/07/22 19:29  7.8  05/13/21  8.5          Neutrophils %  10/07/22 19:29  48              Lymphocytes %  10/07/22 19:29  38              Monocytes %  10/07/22 19:29  9              Eosinophils %  10/07/22 19:29  4              Basophils %  10/07/22 19:29  1              Absolute Neutrophil  10/07/22 19:29  4.0              Absolute Lymphocyte  10/07/22 19:29  3.1              Absolute Monocyte  10/07/22 19:29  0.8              Absolute Eosinophil  10/07/22 19:29  0.3              Absolute Basophil  10/07/22 19:29  0.1               Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  10/07/22 19:29  140  05/13/21  137          Potassium SerPl QN  10/07/22 19:29  3.9  05/13/21  4.1          Chloride SerPl QN  10/07/22 19:29  102  05/13/21  104          Carbon Dioxide SerPl QN  10/07/22 19:29  30  High  05/13/21  24          Anion Gap  10/07/22 19:29  8  05/13/21  9          BUN SerPl QN  10/07/22 19:29  14  05/13/21  19          Creatinine SerPl QN  10/07/22 19:29  0.74  05/13/21  0.69          Estimated GFR (CKD-EPI)  10/07/22 19:29  >90  05/13/21  >90          Estimated GFR (CKD-EPI, no race)  10/07/22 19:29  >90              Estimated CRCL (CG)  10/07/22 19:29  93  05/13/21  109          Glucose SerPl QN  10/07/22 19:29  120  High  05/13/21  184  High          Calcium Total SerPl QN  10/07/22 19:29  9.4  05/13/21  9.4          Alkaline Phos SerPl QN  10/07/22 19:29  41  08/28/21  42          ALT SerPl QN  10/07/22 19:29  20  08/28/21  22          AST SerPl QN  10/07/22 19:29  21  08/28/21  20          Bilirubin Total SerPl QN  10/07/22 19:29  0.4  08/28/21  0.6          Total Protein SerPl QN  10/07/22 19:29  7.5  08/28/21  7.7          Albumin SerPl QN  10/07/22 19:29  4.2  08/28/21  4.3          Urinalysis FS  LATEST RESULTS        Color  10/07/22 19:10  Yellow        Clarity  10/07/22 19:10  Clear        Specific Gravity  10/07/22 19:10  1.025        pH  10/07/22 19:10  6.5        Protein  10/07/22 19:10  Negative        Glucose  10/07/22 19:10  Negative        Ketones  10/07/22 19:10  Negative        Bilirubin  10/07/22 19:10  Negative        Hgb Ur  10/07/22 19:10  Negative        Nitrite  10/07/22 19:10  Negative        Urobilinogen  10/07/22 19:10  2.0 Abnormal        Leukocyte Esterase Ur  10/07/22 19:10  Trace Abnormal        WBC  10/07/22 19:10  0-5        RBC  10/07/22 19:10  0-2        Bacteria  10/07/22 19:10  Few Abnormal        Squamous Epithelial  10/07/22 19:10  Few        Mucous  10/07/22 19:10  Present      Diagnostic Results  CT Abd/Pelvis W/IV Contrast    10/07/22 21:28:18  IMPRESSION:  1. Cholelithiasis without evidence of acute cholecystitis.   2. Mild haziness of the central small bowel mesentery. Broad  differential including but not limited to idiopathic mesenteric  panniculitis, low protein, cirrhosis, pancreatitis, infection,  hemorrhage, less commonly lymphoma. This finding is of uncertain  clinical significance.     Thank you for consulting our team of subspecialty radiologists at Radiology.  Healthcare providers wishing to discuss this case further can contact the Abdominal Imaging Reading Room.  For after-hours or emergency department cases, please calL.   Electronically Signed by:     Signed By: MD      Signature Line Electronically Signed on 10/07/22 21:44  ________________________________________________________   Electronically Signed on 10/07/22 22:28  ________________________________________________________ MD