Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Abdominal pain, Abdominal pain lower, Abdominal tenderness, Alanine aminotransferase normal, Anaemia
Clinical narrative: Document Type: ED Physician Progress Note  Document Subject: ED Progress Note   Performed By: on November 03, 2022 10:03 EDT   Verified By: MD on November 03, 2022 17:52 EDT   Encounter Info: Hospital, Emergency, 11/03/22 - 11/03/22    * Final Report *        Basic Information  Time Seen: MD / 11/03/2022 09:59  Chief Complaint  Diarrhea black Abd pain  History of Present Illness     Patient Seen: 11/03/22 10:08:29 71 year old female presents to the ED via private vehicle c/o lower abd pain and diarrhea onset two days ago.  Patient was sent from the urgent care for evaluation secondary to her lower abdominal pain and black liquid stools over the past two days. She reports pain as an abdominal cramping. Patient is on Plavix which she was told to hold today. Reports one episode of emesis on Tuesday, denies any since then. Denies fever or hematemesis. Denies taking any pain medications PTA.  Surgical hx of hiatal hernia repair, cholecystectomy, and appendectomy. Patient follows with Dr., GI. Family spoke with him prior to coming to the ED.  Review of Systems     Constitutional:  no fever Eyes: no eye pain ENMT:  no sore throat Cardiovascular: no chest pain Respiratory:  no shortness of breath Gastrointestinal:  +abdominal pain Genitourinary:  no dysuria Musculoskeletal:  no back pain Neurologic:  no headache  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.6 DegC  Heart Rate:       104 bpm  Resp Rate:       18 br/min  BP #1:       132 / 65 mmHg  SpO2 (%):       95 %  O2 Device:       Room air     Height CM: 167.6 cm  Weight KG: 81.3 kg  Ideal Body Weight: 59.26 kg     I have reviewed the triage vital signs General:  no acute distress Eye: no conjunctival injection Cardiovascular: rhythm regular, S1S2 within normal limits Respiratory:  lungs clear, respirations non-labored_ Gastrointestinal:  soft, non-distended, diffuse lower abdominal tenderness, no guarding, dark stool on rectal exam, chaperone present at bedside Msk:  NC/AT, extremities without deformity Skin:  warm, dry, no cyanosis Psych: appropriate mood and affect Neurological:  alert, conversant, speech normal  Medical Decision Making     71 year old female presents with lower abdominal pain with dark liquid stools over the past two days.   Labs: reviewed  Radiology: reviewed  Records: reviewed, spoke with the patient's husband today. Patient had left a message with GI clinic yesterday reporting the dark stools, Dr. yesterday ordered a CBC and BMP and recommended holding her Plavix. He had sent in an rx for PPI to her pharmacy.  EKG: 1021. Rate: 102. Rhythm: sinus. Axis: rightward. Intervals: normal. ST segments: nonspecific ST abnormality, appears similar to baseline _  11/03/22 11:33:22   Informed Dr. on results. He is agreeable with plan for admission.  11/03/22 11:37:01   Paged hospitalist for admission.  11/03/22 12:17:31   Dr. will accept the patient to inpatient med surg.            Condition     Stable  Counseled  Counseled patient regarding diagnosis, regarding diagnostic results, regarding treatment plan. Patient indicated understanding of instructions.  Disposition: 11/03/22 12:20:00 admitted to inpatient med surg by Dr.   Attestations  I, scribing for Dr. on 11/03/22 10:03:44 Signed by, scribe, 11/03/22 10:03:44  I, MD, attest that the scribes documentation has been prepared under my direction in person and by me in its entirety.  I confirm that the note above accurately reflects all the work, treatment, procedures, and medical decision-making performed by me.  Assessment/Plan       Acute diverticulitis   K57.92    Anemia   D64.9    Lower abdominal pain   R10.30    Occult blood positive stool   R19.5    SIRS (systemic inflammatory response syndrome)   R65.10       Follow Up  No qualifying data available   Chronic Problem List    Anxiety  Arthritis of hand, degenerative  CAD (coronary artery disease)  Capsulitis of foot  Cervical spinal stenosis  Change in bowel habits  Constipation  Diarrhea  Diverticulosis  Emphysema/COPD  Foot pain  Gout attack  H/O vitamin D deficiency  Hallux abductovalgus  Hammertoe  History of gout  History of TIA (transient ischemic attack)  Hyperlipidemia  IBS (irritable bowel syndrome)  Immunosuppressed status  Impingement syndrome of left shoulder  Left rotator cuff tear  Left shoulder pain  Medication management  Osteopenia  Polycythemia  Prediabetes  QT prolongation  RA - Rheumatoid arthritis  Rheumatoid arthritis  Tobacco use  Toe dislocation  Procedure/Surgical History  ?Eye examination (02/03/2017) ?colonoscopy (12/06/2016) ?egd (11/14/1996) ?Appendectomy ?back ?carpal tunnel ?Cholecystectomy ?cyst right ovary ?Inguinal Hernia Repair ?left heart catherization ?Nissen repair ?Tonsillectomy  Surgical History Internal  04/21/2022    Foot Osteotomy  (Left)    Medications  Home Medications (24) Active acetaminophen 500 mg oral capsule 1,000 mg = 2 Capsule, Orally, Daily albuterol (Eqv-ProAir HFA) 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Daily albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, Neb Inhal, BID amitriptyline 75 mg oral tablet 75 mg = 1 Tablet, Orally, At Bedtime aspirin 81 mg oral tablet, chewable 81 mg = 1 Tablet, Orally, QPM Breo Ellipta 100 mCg-25 mCg inhalation powder 1 Puff, Inhalation, QAM carvedilol 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, BID cholecalciferol (vitamin D3) 50 mCg (2,000 intl units) oral capsule 50 mCg = 1 Capsule, Orally Daliresp 500 mCg oral tablet 500 mCg = 1 Tablet, Orally, Daily escitalopram 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily esomeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily fexofenadine 180 mg oral tablet 180 mg = 1 Tablet, Orally, QPM Flonase 50 mCg/inh nasal spray 1 Spray, Nostrils, Both, Daily ibuprofen 200 mg oral tablet 400 mg = 2 Tablet, PRN, Orally, Daily leflunomide 20 mg oral tablet 1 Tablet, Orally, QAM lisinopril 10 mg oral tablet 10 mg = 1 Tablet, Orally, QPM Medrol Dosepak 4 mg oral tablet See Instructions, Orally, as directed on package labeling Misc Supplies See Instructions, Left cast shoe. nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN Norco 7.5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, TID Plaquenil 200 mg oral tablet 200 mg = 1 Tablet, Orally, BID Plavix 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily rosuvastatin 10 mg oral tablet 10 mg = 1 Tablet, Orally, At Bedtime Spiriva 18 mCg inhalation capsule 18 mCg = 1 Capsule, Inhalation, Daily  Medication Administration   Given  ceftRIAXone, 2 GM, IV Push  fentaNYL, 50 mCg, IV Push  Flagyl, IVPB  ondansetron, 4 mg, IV Push  pantoprazole, 40 mg, IV Push  Sodium Chloride 0.9% - ED Bolus, 1000 mL, IVPB  Allergies   methotrexate (lung issues)  Augmentin (Vomiting, Nausea)  Social History    Alcohol   Current, Wine, 1-2 times per year   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Employed, Work/School description:   Exercise   Exercise type: Walking, Weight lifting, walking/ lifting at work.   Home/Environment   Lives with Spouse.   Nutrition/Health   Type of diet: eats anything she wants.   Substance Abuse   Denies   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.    Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  11/03/22 10:22  19.6  High  09/28/22  7.6          RBC  11/03/22 10:22  3.59  Low  09/28/22  4.14          Hgb  11/03/22 10:22  10.7  Low  09/28/22  12.2          Hct  11/03/22 10:22  32.4  Low  09/28/22  37.2          MCV  11/03/22 10:22  90  09/28/22  90          MCH  11/03/22 10:22  29.7  09/28/22  29.3          MCHC  11/03/22 10:22  32.9  09/28/22  32.7          RDW  11/03/22 10:22  15.4  High  09/28/22  15.5  High          Platelet  11/03/22 10:22  279  09/28/22  345          MPV  11/03/22 10:22  8.1  09/28/22  7.3          Neutrophils %  11/03/22 10:22  77  09/28/22  47          Lymphocytes %  11/03/22 10:22  14  09/28/22  31          Monocytes %  11/03/22 10:22  8  09/28/22  17          Eosinophils %  11/03/22 10:22  1  09/28/22  4          Basophils %  11/03/22 10:22  1  09/28/22  1          Absolute Neutrophil  11/03/22 10:22  15.0  High  09/28/22  3.6          Absolute Lymphocyte  11/03/22 10:22  2.7  09/28/22  2.3          Absolute Monocyte  11/03/22 10:22  1.6  High  09/28/22  1.3          Absolute Eosinophil  11/03/22 10:22  0.2  09/28/22  0.3          Absolute Basophil  11/03/22 10:22  0.1  09/28/22  0.1           Routine Coagulation Studies FS  LATEST RESULTS  HISTORICAL RESULTS          PT  11/03/22 10:22  11.0  08/27/22  11.7          INR  11/03/22 10:22  0.97  08/27/22  1.04           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  11/03/22 10:22  134  Low  09/28/22  137          Potassium SerPl QN  11/03/22 10:22  4.1  09/28/22  3.7          Chloride SerPl QN  11/03/22 10:22  106  09/28/22  98          Carbon Dioxide SerPl QN  11/03/22 10:22  25  09/28/22  31  High          Anion Gap  11/03/22 10:22  3  09/28/22  8          BUN SerPl QN  11/03/22 10:22  48  High  09/28/22  24  High          Creatinine SerPl QN  11/03/22 10:22  0.81  09/28/22  1.11          Estimated GFR (CKD-EPI, no race)  11/03/22 10:22  78  09/28/22  53  Low          Estimated CRCL (CG)  11/03/22 10:22  68  09/28/22  50  Low          Glucose SerPl QN  11/03/22 10:22  101  High  09/28/22  125  High          Calcium Total SerPl QN  11/03/22 10:22  9.4  09/28/22  9.7          Alkaline Phos SerPl QN  11/03/22 10:22  51  09/28/22  84          ALT SerPl QN  11/03/22 10:22  10  09/28/22  14          AST SerPl QN  11/03/22 10:22  10  Low  09/28/22  16          Bilirubin Total SerPl QN  11/03/22 10:22  0.7  09/28/22  0.4          Total Protein SerPl QN  11/03/22 10:22  6.6  09/28/22  7.1          Albumin SerPl QN  11/03/22 10:22  3.9  09/28/22  4.2          Troponin-I High Sensitivity  11/03/22 10:22  9  09/28/22  6          Lactate Venous Pl QN  11/03/22 10:46  0.9  08/26/22  0.9          Fecal Studies FS  LATEST RESULTS        Specimen Type Occult Blood  11/03/22 10:24  Stool        Occult Blood Stool  11/03/22 10:24  Positive Abnormal           Blood Bank Testing  LATEST RESULTS  HISTORICAL RESULTS          ABO Rh  11/03/22 10:22  B Pos  08/27/22  B Pos          IAT Interp  11/03/22 10:22  Neg          Diagnostic Results  CT Abd/Pelvis W/IV Contrast    11/03/22 11:34:38  IMPRESSION:   A 4.3 cm subcapsular structure in the posterior right hepatic lobe is  consistent with a hemangioma and has not changed significantly since  3/6/2018.   Status post cholecystectomy.   Colonic diverticulosis with acute diverticulitis at the junction of  the descending and sigmoid colon. There is no evidence of free air,  abscess or other complication at this time.     Electronically Signed by:     Signed By: MD        Signature Line Electronically Signed on 11/03/22 12:24 EDT ________________________________________________________   Electronically Signed on 11/03/22 17:52 EDT ________________________________________________________ MD