Age: 68.0
Sex: F
Vaccine: FLU4
Symptoms: Fall, Full blood count, Glomerular filtration rate normal, Glucose urine absent, Haematocrit decreased
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: DO on November 21, 2022 21:32 EST   Encounter Info: Emergency, 11/21/22 - 11/22/22    * Preliminary Report *        Basic Information  Time Seen: DO / 11/21/2022 21:23  Chief Complaint  Foot injury - Minor (Complaint of)  Supporting Nursing Comments:  c/o pain in right foot from wound on top of the foot and 2 toes, has not been able to be seen by any wound management. reports that she has a blood clot in each thigh   History of Present Illness     68-year-old female presents to the ER for multiple complaints.   Patient reports that she has had a right foot wound on the top of her foot for over 6 months.  She has not been able to get into wound clinic.  She did try to get into her family doctor however they cannot see her for over a week.  She reports history of blood clots in bilateral lower extremities.  She is taking Lovenox for this.  She states that she is on the Lovenox as she developed worsening clots despite being on oral anticoagulants.  Last ultrasound she reports was about a month ago.  She does not report any new calf pain or swelling.  She has been having ongoing right foot pain.  She did recently have someone stepped on her foot.  Otherwise denies any trauma to her foot.  She has some purple discoloration to several toes that she reports has been present for over a year.  Family member states that she has to areas that have opened up recently yesterday.   Family member also reports patient has been weak and pale.  Today she was so weak she could barely stand.  She noted weakness in her arms and her legs.  As well as all over.  Denies any black or bloody stools.  Patient has a history of anemia.   Denies any head pain.  She did have a recent fall sounds as though she has frequent falls.  She did hit her head.  Denies any loss of consciousness.   She reports chronic neck and back pain however denies any acute change.  No loss of bowel or bladder function.  No unilateral weakness.  Again just the generalized weakness that she noted above.   No vomiting or diarrhea.  No cough or fever.  Review of Systems     All other systems reviewed & negative.  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       36.9 DegC  Heart Rate:       72 bpm  Resp Rate:       22 br/min  BP:       147 / 79 mmHg  SpO2 (%):       100 %  O2 Device:       Room air     Height CM: 162.6 cm  Weight KG: 100 kg  Ideal Body Weight: 54.74 kg     Vital Signs               Per nurse's notes.   Oxygen saturation.  General:  Alert, no acute distress.   Skin:  Warm, dry, intact.   Head:  Normocephalic, ecchymosis to the left chin.  no raccoon eyes .  No septal hematoma. no battle sign. no periorbital ecchymosis or proptosis. Neck:  Supple, trachea midline, no tenderness, no JVD, no carotid bruit.   Eye:  Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva.   Ears, nose, mouth and throat:  Oral mucosa moist, no pharyngeal erythema or exudate.   Cardiovascular:  Normal peripheral perfusion, No edema, clear heart sounds S1 and S2 .   Respiratory:  Lungs are clear to auscultation, respirations are non-labored, breath sounds are equal, Symmetrical chest wall expansion.   Gastrointestinal:  Soft, Nontender, Non distended, Normal bowel sounds.   Musculoskeletal:  Normal ROM, no deformity.   No C, T, or LS midline tenderness, step-offs or deformities.    B/L Radial pulses intact. B/L DP & PT pulses intact. Extremities warm & well perfused.  Right dorsal foot has a about a 4 cm superficial appearing wound.  It is malodorous however no drainage surrounding redness or crepitance.  Chronic skin changes to bilateral lower extremities.  Neurological:  GCS 15. AAO*3, PERRL, EOMI, Visual Fields full, no dysarthria, face symmetric, symmetric facial strength, symmetric facial sensation, tongue midline, uvula raises midline, symmetric shoulder shrugs, hearing intact, no upper extremity drift, symmetric grip strengths, 5/5 MS in both upper extremities, no lower extremity drift, symmetric dorsi & plantar flexion, 5/5 MS in both lower extremities. No limb ataxia. No aphasia or neglect. Sensation intact.  Lymphatics:  No lymphadenopathy.  Psychiatric:  Cooperative.                                Follow Up  No qualifying data available   Chronic Problem List    Acute epigastric pain  Asthma  Bronchitis  CVA (cerebrovascular accident)  Depression  Factor V Leiden  History of DVT in adulthood  Hypothyroidism  Leg edema  Mobility impaired  Port-A-Cath in place  Recurrent deep vein thrombosis (DVT)  S/P IVC filter  Seizure disorder  Severe obesity  Skin change  Tobacco use  Type II diabetes mellitus  Ulcer of bile duct  Procedure/Surgical History  ?back fusion ?back surg x5 ?bil scope of knees ?chole ?hernia repair ?hysterectomy ?pacemaker ?port placement ?right foot surgery ?right shoulder scope ?stomach surgery  Surgical History Internal  12/05/2021    Angiogram      11/23/2016    Portacath Insertion     09/22/2014    EGD ENDO Ultrasound     05/23/2008    Colonscpy Diagnostic/Screen                      Medications  Home Medications (16) Active atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, At Bedtime carBAMazepine 200 mg oral tablet, extended release 400 mg = 2 Tablet, Orally, BID CLonazePAM 0.5 mg oral tablet 0.5 mg = 1 Tablet, Orally, BID cyanocobalamin 1000 mCg/mL injectable solution See Instructions, 1 mL IM once weekly for 4 weeks, then 1 mL IM every 2 weeks x 2 doses then 1 mL IM monthly enoxaparin 40 mg/0.4 mL injectable solution 1 Syringe, Subcutaneous, Daily EPINEPHrine 0.3 mg injectable kit (2 pack) 0.3 mg, PRN, IM, ONCE gabapentin 300 mg oral capsule 300 mg = 1 Capsule, Orally, BID hydroCODONE-acetaminophen 10 mg-325 mg oral tablet See Instructions, 1-2 tablets every 4 to 6 hrs PRN levothyroxine 150 mCg (0.15 mg) oral tablet 150 mCg = 1 Tablet, Orally, Daily Mirapex 1 mg oral tablet 1 mg = 1 Tablet, Orally, TID Misc Supplies See Instructions, Needles and syringes to go with B12 injections omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily PARoxetine 30 mg oral tablet 60 mg = 2 Tablet, Orally, Daily promethazine 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, Q8H tiZANidine , Orally, Daily traZODONE 100 mg oral tablet 100 mg = 1 Tablet, Orally, At Bedtime    Allergies   Ceclor  CeleBREX (rash)  Dilaudid ([D]Chest pain, DIB - Difficulty in breathing)  Keflex  Keppra (rash)  LaMICtal (blisters)  Reglan  Septra  doxycycline (rash)  erythromycin (Rash)  penicillin (Anaphylaxis)  sulfADIAZINE (Rash)  Social History    Alcohol - Denies Alcohol Use   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Hobbies/Interests   watch games shows, reading Creative:. watching farm animals Outdoor:. church Social. Church Activities, Reading Enrichment.   Substance Abuse - Denies Substance Abuse   Denies   Tobacco - Denies Tobacco Use   Tobacco Use: Former smoker, quit more than 30 days ago. Started age 18.0 Years. Stopped age 30 Years.  Family History   Blood clot: Mother.  Breast cancer: Grandmother (P).  Factor 5 Leiden mutation: Sister and Brother.  Heart attack: Father.  Lung cancer: Sister.Negative: Mother, Father and Grandmother (P).  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  11/21/22 22:30  4.3  10/25/22  4.7          RBC  11/21/22 22:30  3.28  Low  10/25/22  3.16  Low          Hgb  11/21/22 22:30  10.7  Low  10/25/22  10.3  Low          Hct  11/21/22 22:30  32.1  Low  10/25/22  30.9  Low          MCV  11/21/22 22:30  98  10/25/22  98          MCH  11/21/22 22:30  32.6  10/25/22  32.6          MCHC  11/21/22 22:30  33.3  10/25/22  33.4          RDW  11/21/22 22:30  14.6  High  10/25/22  15.1  High          Platelet  11/21/22 22:30  135  Low  10/25/22  166          MPV  11/21/22 22:30  7.3  10/25/22  6.8  Low          Neutrophils %  11/21/22 22:30  64  10/25/22  66          Lymphocytes %  11/21/22 22:30  22  10/25/22  23          Monocytes %  11/21/22 22:30  6  10/25/22  7          Eosinophils %  11/21/22 22:30  7  10/25/22  4          Basophils %  11/21/22 22:30  1  10/25/22  1          Absolute Neutrophil  11/21/22 22:30  2.7  10/25/22  3.1          Absolute Lymphocyte  11/21/22 22:30  0.9  Low  10/25/22  1.1          Absolute Monocyte  11/21/22 22:30  0.3  10/25/22  0.3          Absolute Eosinophil  11/21/22 22:30  0.3  10/25/22  0.2          Absolute Basophil  11/21/22 22:30  0.0  10/25/22  0.0           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  11/21/22 22:30  140  10/25/22  143          Potassium SerPl QN  11/21/22 22:30  4.6  10/25/22  3.9          Chloride SerPl QN  11/21/22 22:30  107  10/25/22  108          Carbon Dioxide SerPl QN  11/21/22 22:30  28  10/25/22  27          Anion Gap  11/21/22 22:30  5  10/25/22  8          BUN SerPl QN  11/21/22 22:30  20  10/25/22  18          Creatinine SerPl QN  11/21/22 22:30  0.96  10/25/22  0.84          Estimated GFR (CKD-EPI, no race)  11/21/22 22:30  64  10/25/22  76          Estimated CRCL (CG)  11/21/22 22:30  64  10/25/22  73          Glucose SerPl QN  11/21/22 22:30  143  High  10/25/22  140  High          Calcium Total SerPl QN  11/21/22 22:30  8.2  Low  10/25/22  8.8          Alkaline Phos SerPl QN  11/21/22 22:30  126  High  10/25/22  141  High          ALT SerPl QN  11/21/22 22:30  10  10/25/22  14          AST SerPl QN  11/21/22 22:30  10  Low  10/25/22  14          Bilirubin Total SerPl QN  11/21/22 22:30  0.3  10/25/22  0.3          Total Protein SerPl QN  11/21/22 22:30  5.8  Low  10/25/22  6.2  Low          Albumin SerPl QN  11/21/22 22:30  3.5  10/25/22  3.6          Lipase SerPl QN  11/21/22 22:30  35  03/23/22  22          Troponin-I High Sensitivity  11/21/22 22:30  11  10/25/22  5          BNP Pl QN  11/21/22 22:30  294  High              Lactate Venous Pl QN  11/21/22 22:30  0.8  03/24/22  1.0           Urinalysis FS  LATEST RESULTS  HISTORICAL RESULTS          Color  11/22/22 01:32  Yellow  07/11/22  Yellow          Clarity  11/22/22 01:32  Clear  07/11/22  Clear          Specific Gravity  11/22/22 01:32  1.015  07/11/22  1.020          pH  11/22/22 01:32  7.5  07/11/22  7.0          Protein  11/22/22 01:32  Negative  07/11/22  Negative          Glucose  11/22/22 01:32  Negative  07/11/22  Negative          Ketones  11/22/22 01:32  Negative  07/11/22  Negative          Bilirubin  11/22/22 01:32  Negative  07/11/22  Negative          Hgb Ur  11/22/22 01:32  Negative  07/11/22  Negative          Nitrite  11/22/22 01:32  Negative  07/11/22  Negative          Urobilinogen  11/22/22 01:32  Normal  07/11/22  Normal          Leukocyte Esterase Ur  11/22/22 01:32  Negative  07/11/22  Negative           Molecular Diagnostic Tests  LATEST RESULTS  HISTORICAL RESULTS          COVID 19 Specimen Source  11/21/22 22:41  Nasopharyngeal  10/25/22  Nasopharyngeal          Coronavirus SARS-CoV2 Rapid  11/21/22 22:41  Not Detected  10/25/22  Not Detected           Viral FS  LATEST RESULTS  HISTORICAL RESULTS          Rapid Influenza Method  11/21/22 22:41  PCR - Liat  10/25/22  PCR - Liat          Rapid Influenza A PCR  11/21/22 22:41  Not Detected  10/25/22  Not Detected          Rapid Influenza B PCR  11/21/22 22:41  Not Detected  10/25/22  Not Detected      Diagnostic Results  CT Cervical Spine W/o IV Contrast    11/22/22 00:40:06  IMPRESSION:  1. No evidence of acute fracture or traumatic subluxation in the  cervical spine.     Thank you for consulting our team of subspecialty radiologists at  Radiology. Healthcare providers wishing to discuss  this case further can contact.   Electronically Signed by:     MD     ************************************************** CT Head W/o IV Contrast    11/22/22 00:28:42  IMPRESSION:  1. No acute CT abnormality of the head. No acute intracranial  hemorrhage, hydrocephalus, or large mass     Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discuss  this case further can contact.   Electronically Signed by:     MD     ************************************************** XR Chest PA or AP Portable    11/21/22 23:53:06  IMPRESSION:  Constellation of findings as above be seen with interstitial edema in  the setting of cardiac decompensation. However, underlying  atypical/viral pneumonia can have a similar appearance.   Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss  this case.    Electronically Signed by:     Signed By: MD     ************************************************** XR Foot 3 View Right    11/21/22 23:56:43  IMPRESSION:  1. No acute bony findings, though radiographs are generally not  considered sensitive for the above reasons.  2. There is prominent soft tissue swelling about the foot.  Underlying soft tissue infection cannot be excluded.   Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss  this case further can contact.     Electronically Signed by:     Signed By: MD  EKG  11/21/2022.  10:37 PM.  Rate 64.  Atrial paced rhythm with prolonged AV conduction.  Left bundle branch block.      Signature Line ________________________________________________________ DO