Age: 20.0
Sex: M
Vaccine: COVID19
Symptoms: Phlebolith, Platelet count normal, Protein total normal, Red blood cell count normal, Red cell distribution width normal
Clinical narrative: (M) - 21 y.o. Note Creation:8/3/2022 Encounter Date:7/29/2022     History   Chief Complaint Patient presents with ? Abdominal Pain     Patient is a 21 y.o. male with a hx of ADHD presents to the ED c/o abdominal pain x two days. Patient reports not having a bowel movement in a few days. Patient denies nausea or emesis. Patient denies any other pertinent symptoms or concerns. Patient denies any other aggravating or alleviating factors. Pt denies any other pertinent PMHx.   The history is provided by the patient and medical records. No language interpreter was used.      Past Medical History: Diagnosis Date ? ADHD       Past Surgical History: Procedure Laterality Date ? HX EAR TUBES   2003     No family history on file.   Social History   Tobacco Use ? Smoking status: Current Every Day Smoker     Packs/day: 1.00     Years: 1.00     Pack years: 1.00     Types: Cigarettes, Cigars ? Smokeless tobacco: Never Used Vaping Use ? Vaping Use: Some days ? Substances: Nicotine ? Devices: Disposable Substance Use Topics ? Alcohol use: Not Currently     Alcohol/week: 7.0 standard drinks     Types: 7 Cans of beer per week     Comment: denies alchol use at this time ? Drug use: Yes     Types: Marijuana     Patient is a tobacco user, and I have offered a counseling referral.   No LMP for male patient.   No Known Allergies   Current Outpatient Medications on File Prior to Encounter Medication Sig ? OLANZapine (ZYPREXA) 2.5 mg tablet Take 1 Tablet by mouth At bedtime. ? citalopram (CELEXA) 10 mg tablet Take 1 Tablet by mouth Once Daily. ? [EXPIRED] acamprosate (CAMPRAL) 333 mg DR tablet Take 2 Tabs by mouth Three times a day for 30 days.     Review of Systems   Review of Systems  Constitutional: Negative for activity change, appetite change, chills, fatigue, fever and unexpected weight change.  HENT: Negative for congestion, dental problem, ear discharge, ear pain, facial swelling, hearing loss, nosebleeds, postnasal drip, rhinorrhea, sinus pressure, sneezing, sore throat, tinnitus, trouble swallowing and voice change.   Eyes: Negative for photophobia, pain, discharge, redness and itching.  Respiratory: Negative for cough, choking, chest tightness, shortness of breath, wheezing and stridor.   Cardiovascular: Negative for chest pain, palpitations and leg swelling.  Gastrointestinal: Positive for abdominal pain and constipation. Negative for diarrhea, nausea, rectal pain and vomiting.  Endocrine: Negative for cold intolerance, polydipsia, polyphagia and polyuria.  Genitourinary: Negative for decreased urine volume, difficulty urinating, dysuria, flank pain, frequency, hematuria and urgency.  Musculoskeletal: Negative for arthralgias, back pain, joint swelling and myalgias.  Skin: Negative for pallor, rash and wound.  Neurological: Negative for tremors, seizures, syncope, weakness, numbness and headaches.  Hematological: Negative for adenopathy.  Psychiatric/Behavioral: Negative for agitation, behavioral problems, confusion, hallucinations, self-injury, sleep disturbance and suicidal ideas. The patient is not nervous/anxious.       Physical Exam   ED Triage Vitals [07/29/22 1755] BP BP Manual or Automatic? Patient Position BP Location Heart Rate (Monitor) (!) 95/68 Automatic Sitting Right Arm --   Pulse Pulse Source Respirations Temp Temp Source (!) 120 Radial 18 99.7 °F (37.6 °C) Oral   SpO2 SPO2 Location O2 Delivery O2 Device O2 Flow Rate (l/min) 99 % -- Room air -- --   FIO2 (%) Pain Intensity 1 Exacerbated By Relieved By Quality -- 7 -- -- --   Duration         --             Physical Exam Vitals and nursing note reviewed.  Constitutional:      General: He is not in acute distress.    Appearance: He is well-developed. He is not diaphoretic.  HENT:     Head: Normocephalic and atraumatic.     Nose: Nose normal.     Mouth/Throat:     Pharynx: No oropharyngeal exudate.  Eyes:     General: No scleral icterus.       Left eye: No discharge.     Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:     Vascular: No JVD.  Cardiovascular:     Rate and Rhythm: Regular rhythm. Tachycardia present.     Heart sounds: Normal heart sounds. No murmur heard.   No friction rub. No gallop.  Pulmonary:     Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No stridor. No wheezing or rales.  Chest:     Chest wall: No tenderness.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is generalized abdominal tenderness. There is no guarding or rebound.  Musculoskeletal:        General: No tenderness or deformity. Normal range of motion.     Cervical back: Normal range of motion and neck supple.  Skin:    General: Skin is warm and dry.     Coloration: Skin is not pale.     Findings: No erythema or rash.  Neurological:     Mental Status: He is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Behavior: Behavior normal.        Thought Content: Thought content normal.        Judgment: Judgment normal.        MDM   Treatment: Procedures   Medications NS (sodium chloride 0.9%) IV bolus (0 mL Intravenous Stopped 7/29/22 2040)     Results for orders placed or performed during the hospital encounter of 07/29/22 SARS-CoV-2, QL, PCR (Rapid)   Specimen: Throat Result Value Ref Range   SARS-CoV-2 RNA Detected (A)   Comprehensive Metabolic Panel Result Value Ref Range   SODIUM 136 135 - 145 mmol/L   POTASSIUM 3.5 (L) 3.6 - 5.0 mmol/L   CHLORIDE 101 101 - 111 mmol/L   CO2 28 21 - 31 mmol/L   ANION GAP 7     GLUCOSE 92 70 - 110 mg/dL   CREATININE 1.0 0.6 - 1.2 mg/dL   BUN 12 2 - 32 mg/dL   CALCIUM 8.9 8.5 - 10.5 mg/dL   PROTEIN TOTAL 7.0 6.1 - 7.8 g/dL   Albumin 4.5 3.2 - 5.0 g/dL   T BILIRUBIN 0.4 0.2 - 1.0 mg/dL   ALP 54 42 - 121 [iU]/L   AST 24 10 - 42 [iU]/L   ALT (SGPT) 37 10 - 60 [iU]/L   OSMOLALITY 271 266 - 309   A/G Ratio 1.8     B/C 12 10 - 20   ESTIMATED GFR >90 mL/min CBC Result Value Ref Range   WBC 8.7 4.5 - 11.0 10*3/uL   RBC 5.29 4.50 - 5.90 10*6/uL   HGB 15.1 13.5 - 17.5 g/dL   HCT 46.3 37.0 - 53.0 %   MCV 87.5 80.0 - 100.0 fL   MCHC 32.6 32.0 - 36.0 g/dL   MCH 28.5 26.0 - 34.0 pg   RDW 14.3 10.7 - 18.7 %   MPV 7.6 6.5 - 10.0 fL   Platelet Cnt 181 150 - 450 10*3/uL   Differential Type Auto     Neutrophils 72.1 (H) 35.0 - 66.0 %   Lymphocytes 14.7 (L) 24.0 - 44.0 %   Monocytes 12.5 2.1 - 13.3 %   Eosinophils 0.3 0.3 - 5.0 %   Basophils 0.4 0.0 - 1.0 %   Neutrophils Abs 6.3 1.5 - 8.5 10*3/uL   Lymphocytes Abs 1.3 1.1 - 5.0 10*3/uL   Monocytes Abs 1.1 0.0 - 1.4 10*3/uL   Eosinophils Abs 0.0 0.0 - 0.5 10*3/uL   Basophils Abs 0.0 0.0 - 0.1 10*3/uL Lipase Result Value Ref Range   LIPASE 11 11 - 82 U/L     Results         CT Abdomen & Pelvis-NO CONTRAST (Final result)  Result time 07/29/22 20:13:53     Final result             Impression:    IMPRESSION:  1. Single calcified gallstone.  2. Minor amount of non-specific free pelvic fluid.  THIS DOCUMENT HAS BEEN ELECTRONICALLY SIGNED on 07/29/2022  08:13 PM        Narrative:    PROCEDURE INFORMATION:  Exam: CT Abdomen And Pelvis Without Contrast  Exam date and time: 7/29/2022 7:42 PM  Age: 21 years old  Clinical indication: Abdominal pain; Generalized  TECHNIQUE:  Imaging protocol: Computed tomography of the abdomen and pelvis without  contrast.  Radiation optimization: All CT scans at this facility use at least one of these  dose optimization techniques: automated exposure control; mA and/or kV  adjustment per patient size (includes targeted exams where dose is matched to  clinical indication); or iterative reconstruction.  COMPARISON:  No relevant prior studies available.  FINDINGS:  Lungs: The visualized lung bases are clear.  Pleural spaces: There are no pleural effusions.  Heart: The visualized portions of the heart are unremarkable. There is no  evidence of pericardial fluid collections.  Liver: Evaluation of the liver is limited without contrast but the liver is  within normal limits for this noncontrast study.  Gallbladder and bile ducts: There is a single calcified gallstone.  Pancreas: Normal. No ductal dilation.  Spleen: The spleen is normal.  Adrenal glands: Normal. No mass.  Kidneys and ureters: The kidneys are normal.  Stomach and bowel: The stomach is normal. The duodenum is unremarkable. Lack of  gastrointestinal contrast limits evaluation of bowel. Lack of gastrointestinal  contrast limits evaluation of bowel. The colon is normal. Unopacified loops of  small bowel are within range of normal.  Appendix: No evidence of appendicitis.  Intraperitoneal space: No evidence of intraperitoneal free air. There is a  minor amount of free pelvic fluid present.  Vasculature: There are numerous benign phleboliths in the pelvis.  Lymph nodes: There is no evidence of pathologic adenopathy. There are a few  scattered lymph nodes in the right mid abdomen, not of pathologic significance  by CT size criteria.  Urinary bladder: The bladder is normal.  Reproductive: The prostate and seminal vesicles are normal. Bones/joints: There is mild pectus deformity. There is no evidence of acute  fracture.  Soft tissues: Unremarkable.  Other findings: Evaluation is limited by the lack of intravenous contrast.               Preliminary result             Impression:    This exam has been sent for reading.  The final report is not yet available.                   Plan:   ED RECHECK: Discharge: The pt is awake, alert and well appearing at time of reevaluation. I spoke with the patient about his ED work up, diagnosis and any further treatment. I discussed the importance of following up with  and his PCP. I instructed him 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.   MDM   Progress Note:     ED Prescriptions    Medication Sig Dispense Start Date End Date Auth. Provider   ondansetron HCL (ZOFRAN) 4 mg tablet (Expired) Take 1 Tablet by mouth Every 6 hours as needed for up to 3 days. 12 Tablet 7/29/2022 8/1/2022       Final diagnoses: COVID Abdominal pain     ED Disposition     ED Disposition Discharge After Treatment   Condition Stable   Comment --