Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Activated partial thromboplastin time shortened, Alanine aminotransferase normal, Anaemia, Anion gap, Antibody test negative
Clinical narrative: (F) - 78 y.o. Note Creation:8/26/2022 Encounter Date:8/24/2022     History   Chief Complaint Patient presents with ? Abnormal Labs     Pt is a 78 y.o. female with a hx of Esophagitis, bleeding ulcer, anemia who presents to ED after call for abnormal labs for the evaluation of anemia onset chronic but below 7 yesterday.  T has known chronic GI blood loss and recurrent anemia. Pt reports increased stress due to death of husband yesterday.    Pt denies Fever, CP, SOA, and any other pertinent symptoms or concerns.  The patient denies any other aggravating or alleviating factors. The patient denies any other pertinent PMHx.           Past Medical History: Diagnosis Date ? Abnormal stress test   ? Anemia   ? Blood transfusion   ? CAD (coronary artery disease)   ? CHF (congestive heart failure)   ? Cholelithiases   ? Colon polyp   ? Connective tissue disease   ? CVA (cerebral vascular accident)   ? Diverticulitis   ? Diverticulosis   ? Encopresis   ? Esophagus perforation   ? Fatigue   ? Food intolerance   ? Gastric AVM   ? GERD (gastroesophageal reflux disease)   ? Hemorrhoids   ? Hemorrhoids with complication   ? Hernia     hiatal ? HH (hiatus hernia)   ? Hypertension   ? Iron deficiency anemia   ? Lung disease   ? Mitral valve regurgitation   ? Nocturnal hypoxia   ? Palpitations   ? Pneumonia   ? PUD (peptic ulcer disease)   ? Pulmonary arterial hypertension   ? Pulmonary hypertension   ? Pulmonary nodule   ? Raynaud's disease without gangrene   ? Shortness of breath   ? Skin cancer     nod bcc ? SOB (shortness of breath)   ? Stroke     tia ? Thyroid nodule   ? TIA (transient ischemic attack)       Past Surgical History: Procedure Laterality Date ? BIOPSY     ? ENDOSCOPY, COLON, DIAGNOSTIC     ? HX CARDIAC CATHETERIZATION       NO STENT ? HX CHOLECYSTECTOMY   2009 ? HX COLON SURGERY       colonoscopy ? HX COLONOSCOPY N/A 7/1/2014   COLONOSCOPY performed by MD  ? HX COLONOSCOPY N/A 4/14/2021   COLONOSCOPY /C POLYPECTOMY VIA SNARE(HOT) performed by MD at  ? HX EGJ N/A 6/7/2019   EGD /C BIOPSY performed by MD ? HX EGJ N/A 11/8/2018   EGD /C BIOPSY performed by MD  ? HX EGJ N/A 11/8/2018   EGD /C POLYPECTOMY VIA FORCEP performed by MD  ? HX EGJ N/A 11/8/2018   EGD /C ARGON PLASMA COAGULATION performed by MD ? HX EGJ N/A 10/20/2016   EGD /C ARGON PLASMA COAGULATION performed by MD  ? HX EGJ N/A 10/20/2016   EGD /C POLYPECTOMY VIA FORCEP performed by MD ? HX EGJ N/A 7/1/2014   EGD /C BIOPSY performed by MD  ? HX EGJ   7/1/2014   EGD /C POLYPECTOMY VIA FORCEP performed by MD ? HX EGJ   7/1/2014   EGD /C ARGON PLASMA COAGULATION performed by MD  ? HX EGJ   7/1/2014   EGD /C CYTOLOGY performed by MD ? HX EGJ N/A 6/28/2012   EGD /C BIOPSY performed by MD  ? HX EGJ   6/28/2012   EGD /C POLYPECTOMY VIA FORCEP performed by MD ? HX EGJ N/A 12/28/2011   EGD /C BIOPSY performed by MD ? HX EGJ   12/28/2011   EGD /C POLYPECTOMY VIA FORCEP performed by MD ? HX EGJ N/A 4/14/2021   EGD /C BIOPSY performed by MD ? HX EGJ   4/14/2021   EGD /C GOLD PROBE CAUTERY performed by MD ? HX ENTEROSCOPY PUSH N/A 8/17/2022   ENTEROSCOPY PUSH /C GOLD PROBE THERAPY performed by MD ? HX ENTEROSCOPY PUSH   8/17/2022   ENTEROSCOPY PUSH /C ARGON PLASMA COAGULATION performed by MD ? HX ERCP   9/13/2015   ERCP /C CHOLANGIOGRAM performed by MD  ? HX ERCP   9/13/2015   ERCP /C PAPILLOTOMY/SPHINCTEROTOMY performed by MD ? HX ERCP   9/13/2015   ERCP /C BALLOON SWEEP performed by MD  ? HX LIVER BIOPSY     ? HX OTHER SURGICAL HISTORY   03/15/2022   rectopexy  ? HX POLYPECTOMY     ? HX RECTAL EXAM UNDER ANESTHESIA N/A 10/28/2021   RECTAL EXAM UNDER ANESTHESIA performed by MD  ? HX SKIN CANCER REMOVAL       basil cell ? HX SKIN CANCER REMOVAL Right     right forearm ? HX TUBAL LIGATION     ? HX UPPER GI ENDOSCOPY     ? LEFT HEART CATH Right 10/8/2020   Left heart cath performed by DO ? PR REMOVAL GALLBLADDER     ? PR UPPER GI ENDOSCOPY,EXAM     ? RIGHT HEART CATH N/A 10/8/2020   Right heart cath performed by DO     Family History Problem Relation Age of Onset ? Cancer Mother         colon ? Heart Disease Mother   ? Colon Cancer Mother   ? Colon Polyps Mother   ? Cancer Father         Lung Cancer / Bone Cancer ? Breast Cancer Sister         age 65 ? Diabetes Sister   ? Breast Cancer Paternal Aunt         Breast Cancer     Social History   Tobacco Use ? Smoking status: Never Smoker ? Smokeless tobacco: Never Used Vaping Use ? Vaping Use: Never used Substance Use Topics ? Alcohol use: No ? Drug use: No     Patient is not a tobacco user.   No LMP recorded. Patient is postmenopausal.   Allergies Allergen Reactions ? Codeine Nausea Only ? Morphine Nausea Only ? Atorvastatin Nausea And Vomiting     Vomiting nonstop for 24 hours. Was 108lbs before, 102lbs afterward.  ? Isoleucine(L-Isoleucine) Nausea And Vomiting     Current Outpatient Medications on File Prior to Encounter Medication Sig ? ipratropium (ATROVENT) 0.03 % nasal spray Spray 2 Sprays in nose Twice a day. ? ascorbic acid, vitamin C, 500 mg tablet Take 1 Tablet by mouth Twice a day. ? cholecalciferol, vitamin D3, 4,000 unit Tab Take 4,000 Units by mouth Once Daily. Indications: COVID-19 Positive ? cyanocobalamin 1,000 mcg tablet Take 1 Tablet by mouth Once Daily. ? melatonin 3 mg tablet Take 2 Tabs by mouth At bedtime. ? pantoprazole (PROTONIX) 40 mg DR tablet Take 1 Tablet by mouth Twice a day. ? sucralfate (CARAFATE) 1 gram tablet Take 1 Tablet by mouth Before meals and at bedtime. ? lidocaine (LIDODERM) 5 %(700 mg/patch) patch 2 Patches by Transdermal route Once Daily. ? tadalafiL, pulm. hypertension, (ADCIRCA) 20 mg tablet Take 2 Tabs by mouth Once Daily. ? RT OXYGEN PER DELIVERY DEVICE 2 L/min by Nasal Cannula route RT Continuous. Indications: low o2 ? acetaminophen (TYLENOL) 325 mg tablet Take 325 mg by mouth Three times a day. Indications: pain ? macitentan (OPSUMIT) 10 mg Tab Take 1 Tablet by mouth Daily. ? OXYGEN-AIR DELIVERY SYSTEMS 2 liters ? albuterol (VENTOLIN HFA) 90 mcg/Actuation inhaler Take 1-2 Puffs by inhalation Every 6 hours as needed (WHEEZING). ? folic acid (FOLVITE) 1 mg tablet Take 1 Tablet by mouth Twice a day. ? senna (SENNA) 8.6 mg tablet Take 1 Tab by mouth Twice a day. (Patient taking differently: Take 8.6 mg by mouth Twice a day. Prn) ? CALCIUM CARBONATE/VITAMIN D3 (CALCIUM + D PO) Daily.      Review of Systems   Review of Systems  Constitutional: Positive for fever. Negative for appetite change and chills.  HENT: Negative for congestion, facial swelling, rhinorrhea, sore throat and trouble swallowing.   Eyes: Negative for visual disturbance.  Respiratory: Negative for cough and shortness of breath.   Cardiovascular: Negative for chest pain and palpitations.  Gastrointestinal: Positive for blood in stool, nausea and vomiting. Negative for abdominal pain, constipation and diarrhea.  Endocrine: Negative for polydipsia, polyphagia and polyuria.  Genitourinary: Negative for dysuria and flank pain.  Musculoskeletal: Negative for arthralgias, back pain and neck pain.  Skin: Positive for pallor. Negative for rash.  Allergic/Immunologic: Negative for immunocompromised state.  Neurological: Negative for dizziness, seizures, syncope, weakness, light-headedness and headaches.  Hematological: Does not bruise/bleed easily.  Psychiatric/Behavioral: Negative for behavioral problems and suicidal ideas.  All other systems reviewed and are negative.     Physical Exam   ED Triage Vitals BP BP Manual or Automatic? Patient Position BP Location Heart Rate (Monitor) 08/24/22 2008 08/25/22 0411 08/25/22 0411 08/25/22 0411 -- 156/72 Automatic Sitting Right Arm     Pulse Pulse Source Respirations Temp Temp Source 08/24/22 2008 -- 08/24/22 2008 08/24/22 2008 08/25/22 0703 87   18 98 °F (36.7 °C) Oral   SpO2 SPO2 Location O2 Delivery O2 Device O2 Flow Rate (l/min) 08/24/22 2008 -- 08/25/22 0411 -- -- 93 %   Room air       FIO2 (%) Pain Intensity 1 Exacerbated By Relieved By Quality -- -- -- -- --             Duration         --                       Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: She is not in acute distress.    Appearance: She is well-developed. She is not ill-appearing, toxic-appearing or diaphoretic.     Comments: Thin and frail  HENT:     Head: Normocephalic and atraumatic.     Right Ear: External ear normal.     Left Ear: External ear normal.     Nose: Nose normal. No congestion or rhinorrhea.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: Oropharynx is clear.  Eyes:     General: No scleral icterus.       Right eye: No discharge.        Left eye: No discharge.     Extraocular Movements: Extraocular movements intact.     Conjunctiva/sclera: Conjunctivae normal.  Cardiovascular:     Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No stridor. No wheezing, rhonchi or rales.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no guarding.  Musculoskeletal:        General: No deformity or signs of injury. Normal range of motion.     Cervical back: Normal range of motion and neck supple. No rigidity.  Skin:    General: Skin is warm and dry.     Capillary Refill: Capillary refill takes less than 2 seconds.     Coloration: Skin is pale. Skin is not jaundiced.  Neurological:     General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Sensory: No sensory deficit.     Motor: No weakness.     Coordination: Coordination normal.     Gait: Gait normal.  Psychiatric:        Mood and Affect: Mood normal.        Behavior: Behavior normal.        MDM   Treatment: Procedures   Medications ondansetron hcl (PF) (ZOFRAN) injection 4 mg (4 mg Intravenous Given 8/25/22 0700) pantoprazole (PROTONIX) injection 40 mg (40 mg Intravenous Given 8/25/22 0701) famotidine (PF) (PEPCID) injection 20 mg (20 mg Intravenous Given 8/25/22 0700)     Results for orders placed or performed during the hospital encounter of 08/25/22 CBC Result Value Ref Range   WBC 5.2 4.5 - 11.0 10*3/uL   RBC 3.08 (L) 4.00 - 5.20 10*6/uL   HGB 6.8 (LL) 12.0 - 16.0 g/dL   HCT 22.0 (L) 33.0 - 51.0 %   MCV 71.3 (L) 80.0 - 100.0 fL   MCHC 30.9 (L) 32.0 - 36.0 g/dL   MCH 22.0 (L) 26.0 - 34.0 pg   RDW 25.9 (H) 10.7 - 18.7 %   MPV 7.2 6.5 - 10.0 fL   Platelet Cnt 324 150 - 450 10*3/uL   Differential Type Auto     Neutrophils 68.1 (H) 35.0 - 66.0 %   Lymphocytes 18.7 (L) 24.0 - 44.0 %   Monocytes 7.5 2.1 - 13.3 %   Eosinophils 4.7 0.3 - 5.0 %   Basophils 1.0 0.0 - 1.0 %   Neutrophils Abs 3.6 1.5 - 8.5 10*3/uL   Lymphocytes Abs 1.0 (L) 1.1 - 5.0 10*3/uL   Monocytes Abs 0.4 0.0 - 1.4 10*3/uL   Eosinophils Abs 0.2 0.0 - 0.5 10*3/uL   Basophils Abs 0.1 0.0 - 0.1 10*3/uL Comprehensive Metabolic Panel Result Value Ref Range   SODIUM 143 135 - 145 mmol/L   POTASSIUM 4.1 3.6 - 5.0 mmol/L   CHLORIDE 112 (H) 101 - 111 mmol/L   CO2 28 21 - 31 mmol/L   ANION GAP 3     GLUCOSE 111 (H) 70 - 110 mg/dL   CREATININE 0.7 0.4 - 1.0 mg/dL   BUN 24 2 - 32 mg/dL   CALCIUM 9.1 8.5 - 10.5 mg/dL   PROTEIN TOTAL 5.7 (L) 6.1 - 7.8 g/dL   Albumin 3.5 3.2 - 5.0 g/dL   T BILIRUBIN 0.3 0.2 - 1.0 mg/dL   ALP 56 42 - 121 [iU]/L   AST 10 10 - 42 [iU]/L   ALT (SGPT) 7 (L) 10 - 60 [iU]/L   OSMOLALITY 290 266 - 309   A/G Ratio 1.6     B/C 34 (H) 10 - 20   ESTIMATED GFR 81 mL/min PT/APTT/INR Result Value Ref Range   PROTIME 11.8 10.1 - 13.8 s   INR 1.0 0.9 - 1.1   APTT 29.6 23.6 - 37.2 s Type and Screen Result Value Ref Range   ABO AND RH TYPE A POS     Antibody Screen NEG   CROSSMATCH RBC L/R Result Value Ref Range   RBC L/R W201622531857      p.Transfused     RBC L/R W203522679700      p.Transfused       Results  None       Consult:       Plan:   ED RECHECK: Discharge: The pt is awake, alert and well appearing at time of reevaluation. I spoke with the patient about her ED work up, diagnosis and any further treatment. I discussed the importance of following up with  her PCP. I instructed her to return to the Emergency Room for new or worsening symptoms. All of the pt's questions were answered. The patient verbalized understanding. The patient is stable at time of discharge.