Age: 26.0
Sex: F
Vaccine: COVID19
Symptoms: Cholelithiasis, Computerised tomogram abdomen abnormal, Creatinine renal clearance increased, Culture urine, Differential white blood cell count
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: NP on December 10, 2022 14:48   Encounter Info: Emergency, 12/10/22 -     * Preliminary Report *        Basic Information  Time Seen:  NP / 12/10/2022 11:49  Chief Complaint  Abdominal pain (Complaint of)  History of Present Illness     12/10/22 11:56:59  upper abdominal pain.  Known chololithiasis.  Surgery cholecystectomy with Dr scheduled 12/21.  Patient COVID positive day 4.  Was seen yesterday for similar complaints.  Felt pain relief while in department but pain is not tolerable.  Has noticed pain is more frequent and less tolerable.  Nausea without vomiting.  No fevers/chills.  Review of Systems     Constitutional:  No fevers,  no chills,  no sweats Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No ear pain,  no nasal congestion,  no sore throat Respiratory:  No shortness of breath,  no cough,  no wheeze Cardiovascular:  No chest pain,  no palpitations,  no edema Gastrointestinal:  + Abdominal pain,  + nausea,  no vomiting,  no diarrhea,  no constipation Genitourinary:  No frequency,  no urgency,  no dysuria,  no hematuria Hematologic/Lymphatic:  No bruising,  no enlarged lymph nodes Allergic/Immunologic:  No hives Endocrine:  No cold intolerance,  no heat intolerance,  no polyuria,  no polydipsia Musculoskeletal:  No arthralgia,  no myalgia Skin:  No rash,  no pruritus Neurological:  No headache,  no focal weakness,  no numbness Psychiatric:  No anxiety,  no depression  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       37.6 DegC  Heart Rate:       68 bpm  Resp Rate:       18 br/min  BP:       138 / 92 mmHg  SpO2 (%):       96 %  O2 Device:       Room air     Height CM: 167.6 cm  Weight KG: 100 kg  Ideal Body Weight: 59.26 kg      General:  alert, no acute distress Skin:  warm, dry Head:  no trauma, normocephalic Neck:  trachea midline, no adenopathy, no tenderness Eye:  normal conjunctiva, clearsclera Cardiovascular:  regularrate and rhythm, normalperipheral perfusion Respiratory:  Lungs CTA, respirations non-labored Chest wall:  no deformity Gastrointestinal:  soft, non-distended, mild tenderness RUQ, no guarding _ Extremities:  no deformity, no trauma 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     Chart Review: ED RN notes, prior chart review   EKG:   Labs: reviewed  Diagnostic Imaging: reviewed   Dr is out of town until 12/20.  Will consult with Gen Surgeon.                 Assessment/Plan       Orders:   Auto Diff  CBC w/Differential  Comp Metabolic Panel  CT Abd/Pelvis W/IV Contrast  Lipase SerPl QN  Peripheral IV Insertion  Preg Test Ur  UA Microscopic  Urinalysis w Culture Rflx     Follow Up  No qualifying data available   Chronic Problem List    Abn 50g  Back pain  Change in mole  Depression  Gestational hypertension  Obesity, Class II, BMI 35-39.9  Possible IUGR, resolved  Procedure/Surgical History  ?bilateral bunyon removal    Medications  Home Medications (4) Active norethindrone 0.35 mg oral tablet 0.35 mg = 1 Tablet, Orally, Daily, start 3 weeks post-delivery omeprazole 20 mg oral delayed release tablet 20 mg = 1 Tablet, Orally, Daily promethazine 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, Q4H sertraline 100 mg oral tablet 200 mg = 2 Tablet, Orally, Daily  Medication Administration   Given  ketoROLAC, 15 mg, IV Push  morphine inj ED, 4 mg, IV Push  ondansetron, 4 mg, IV Push  Sodium Chloride 0.9% - ED Bolus, 1000 mL, IVPB  Allergies   No Known Medication Allergies  Social History    Alcohol   Current, Beer, Wine, Liquor, 1-2 times per month   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Unemployed, Work/School description: Stay at home Mother. Highest education level: Some college.   Exercise   Exercise frequency: 3-4 times/week. Exercise type: Walking.   Home/Environment   FOB: (Married 5/2018), Lives with Spouse, their daughter.   Nutrition/Health   Diet: Regular. Caffeine intake amount: 1 cup coffee daily.   Other   ACE: 1   Psychosocial   None   Sexual   Sexually active: Yes. Uses condoms: No. Other contraceptive use: Denies any history of abuse. ACE:1.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Alcoholism /alcohol abuse...: Grandfather (M).  Brain aneurysm...: Mother.  Depression: Sister.  Heart disease..: Grandmother (M).  Hypothyroidism...: Father.  Grandmother (P): History is negative  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  12/10/22 12:13  6.2  12/09/22  7.0          RBC  12/10/22 12:13  4.98  12/09/22  4.92          Hgb  12/10/22 12:13  13.3  12/09/22  13.2          Hct  12/10/22 12:13  41.3  12/09/22  40.7          MCV  12/10/22 12:13  83  12/09/22  83          MCH  12/10/22 12:13  26.8  Low  12/09/22  26.8  Low          MCHC  12/10/22 12:13  32.3  12/09/22  32.4          RDW  12/10/22 12:13  14.3  12/09/22  14.0          Platelet  12/10/22 12:13  322  12/09/22  287          MPV  12/10/22 12:13  8.8  12/09/22  8.7          Neutrophils %  12/10/22 12:13  77  12/09/22  59          Lymphocytes %  12/10/22 12:13  16  12/09/22  27          Monocytes %  12/10/22 12:13  6  12/09/22  12          Eosinophils %  12/10/22 12:13  0  12/09/22  2          Basophils %  12/10/22 12:13  0  12/09/22  1          Absolute Neutrophil  12/10/22 12:13  4.8  12/09/22  4.1          Absolute Lymphocyte  12/10/22 12:13  1.0  12/09/22  1.9          Absolute Monocyte  12/10/22 12:13  0.4  12/09/22  0.8          Absolute Eosinophil  12/10/22 12:13  0.0  12/09/22  0.1          Absolute Basophil  12/10/22 12:13  0.0  12/09/22  0.0           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  12/10/22 12:13  137  12/09/22  143          Potassium SerPl QN  12/10/22 12:13  5.0  12/09/22  3.8          Chloride SerPl QN  12/10/22 12:13  106  12/09/22  105          Carbon Dioxide SerPl QN  12/10/22 12:13  27  12/09/22  28          Anion Gap  12/10/22 12:13  4  12/09/22  10          BUN SerPl QN  12/10/22 12:13  12  12/09/22  17          Creatinine SerPl QN  12/10/22 12:13  0.54  Low  12/09/22  0.63          Estimated GFR (CKD-EPI, no race)  12/10/22 12:13  >90  12/09/22  >90          Estimated CRCL (CG)  12/10/22 12:13  >120  12/09/22  >120          Glucose SerPl QN  12/10/22 12:13  99  12/09/22  101  High          Calcium Total SerPl QN  12/10/22 12:13  10.7  High  12/09/22  10.4          Alkaline Phos SerPl QN  12/10/22 12:13  169  High  12/09/22  79          ALT SerPl QN  12/10/22 12:13  481  High  12/09/22  17          AST SerPl QN  12/10/22 12:13  561  High  12/09/22  26          Bilirubin Total SerPl QN  12/10/22 12:13  2.5  High  12/09/22  0.5          Total Protein SerPl QN  12/10/22 12:13  7.6  12/09/22  7.1          Albumin SerPl QN  12/10/22 12:13  4.5  12/09/22  4.3          Lipase SerPl QN  12/10/22 12:13  27  12/09/22  28           Urine Studies FS  LATEST RESULTS  HISTORICAL RESULTS          Pregnancy Test Urine  12/10/22 13:43  Negative  11/27/22  Negative           Urinalysis FS  LATEST RESULTS  HISTORICAL RESULTS          Color  12/10/22 13:43  Yellow  11/27/22  Yellow          Clarity  12/10/22 13:43  Clear  11/27/22  Clear          Specific Gravity  12/10/22 13:43  >=1.030  11/27/22  >=1.030          pH  12/10/22 13:43  5.5  11/27/22  6.0          Protein  12/10/22 13:43  Trace Abnormal  11/27/22  Negative          Glucose  12/10/22 13:43  100 Abnormal  11/27/22  Negative          Ketones  12/10/22 13:43  15 Abnormal  11/27/22  Negative          Bilirubin  12/10/22 13:43  See Comment Abnormal  11/27/22  Negative          Hgb Ur  12/10/22 13:43  Negative  11/27/22  Negative          Nitrite  12/10/22 13:43  Negative  11/27/22  Negative          Urobilinogen  12/10/22 13:43  2.0 Abnormal  11/27/22  Normal          Leukocyte Esterase Ur  12/10/22 13:43  Trace Abnormal  11/27/22  Negative      Diagnostic Results  CT Abd/Pelvis W/IV Contrast    12/10/22 14:28:12  IMPRESSION:  1. Gallstones and biliary sludge with mild gallbladder wall  thickening. Correlate clinically for evidence of acute cholecystitis,  these imaging features would be supportive.  2. Mildly enlarged central bile ducts including the extrahepatic  duct 7 to 8 mm. No calcified stones are seen in the duct. Correlate  with biliary obstructive labs and may consider follow-up in excluding choledocholithiasis.     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 ________________________________________________________ NP