Age: 70.0
Sex: F
Vaccine: COVID19
Symptoms: Respiratory tract congestion, Rotator cuff syndrome, SARS-CoV-2 test, Scan with contrast, Systemic inflammatory response syndrome
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: on May 25, 2023 22:10 EDT   Verified By: MD on May 26, 2023 01:59 EDT   Encounter Info: Hospital, Observation, 05/25/23 -     * Final Report *        Basic Information  Time Seen:  MD / 05/25/2023 22:03  Chief Complaint  Chest pain (Complaint of)  BD C  History of Present Illness     71 year old female with past medical history of T2DM, HTN, HLD, GERD, OSA on CPAP, morbid obesity, chronic pain and opioid use (on Norco 10mg 6 times daily) presents to the ED with a multitude of complaints, chief complaints of chest pain onset today around 15:30 and nausea/vomiting. Patient localizes chest pain to the left sided anterior chest wall. Describes pain as sharp and dull. States pain has been constant since it began without any modifying factors. She endorses abdominal pain as well, and states that this is not typical for her. She reports chronic dyspnea without any acute worsening with the chest pain. She complains of acute on chronic lumbar pain (history of chronic pain related to lumbar DDD), though denies any acute incontinence, saddle anesthesia, or numbness in the extremities. Patient additionally complains of acute on chronic cough. States she has been unable to keep down her home Norco tablets at home today secondary to her nausea/vomiting. Patient was recently treated for a UTI, and she called office today concerned she still may need antibiotics due to color of her urine.  Review of Systems     See HPI  Physical Exam/Objective  Vitals & Measurements most recent  T: 36.7 °C (Oral)  BP: 178/93  HR: 94 (Monitored)  RR: 20  SpO2: 98%  Oxygen Therapy: Room air  WT: 101.10 kg (WFC)  HT: 162.6 cm      I have reviewed the triage vital signs General:  mild distress Eye: no conjunctival injection Cardiovascular: rhythm regular, S1S2 within normal limits Respiratory:  lungs clear, respirations non-labored_ Gastrointestinal:  soft, non-distended, LLQ tenderness, no guarding  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 to the ED with chest pain and multiple other complaints.  A broad differential was considered.  Heart score moderate risk.  PERC positive.  ED course:  I independently reviewed EKG: performed 22:06. Rate: 97 Rhythm: sinus. Axis: normal. Intervals: prolonged QTc. ST segments: no ST  depression or elevation   Patient's labs show leukocytosis at 15.6, mild anemia at 11.7, elevated D dimer at 645, mild hyperglycemia but otherwise stable electrolytes, baseline renal function, normal LFTs, normal lipase, normal bilirubin, mildly elevated initial troponin at 25  05/26/23 00:22:38 SIRS criteria noted.  She has a nearly pan positive review of systems and I am not convinced there is an infectious source at this time.  She is getting appropriate CT imaging which should identify a source if present.  Will reassess need for antibiotics if a source is identified.  05/26/23 01:26:59 delta troponin greater than 5, messaged bed desk for admission.  Patient agreeable with plan.  05/26/23 01:29 Dr. accepts patient to MedSurg obs          Condition     Stable Disposition: 05/26/23 01:29 Admitted, accepted by Dr., obs med-surg  Assessment/Plan       1. Chest pain   R07.9    2. Low back pain   M54.50    3. Left lower quadrant abdominal pain   R10.32    4. Chronic pain syndrome   G89.4    5. BMI 36.0-36.9,adult   Z68.36    6. Chronic, continuous use of opioids   F11.90    7. DDD (degenerative disc disease), lumbar   M51.36    8. Type 2 diabetes mellitus with diabetic polyneuropathy   E11.42    9. Impingement syndrome of right shoulder   M75.41    Orders:   morphine, 4 mg, IV Push, Injection, Q10min, PRN, Pain Severe IV (7-10 out of 10), 05/25/23 23:09:00 EDT, for 3 Doses, Limited # of times  Auto Diff  Bed Request (Decision to Admit)  Cardiac Monitor  CBC w/Differential  Comp Metabolic Panel  COVID 19 PCR  CT Abd/Pelvis W/IV Contrast  CTA Chest Pulm Embolism W/IV Contrast  D-Dimer Pl QN  Electrocardiogram  Lipase SerPl QN  Peripheral IV Insertion  PTINR  Troponin-I High Sensitivity  Troponin-I High Sensitivity  UA Microscopic  Urinalysis w Culture Rflx  XR Chest PA or AP Portable     Follow Up  No qualifying data available   Chronic Problem List    Arthritis of carpometacarpal (CMC) joint of right thumb  Arthritis of shoulder region, left  Asthma  Back pain  BMI 36.0-36.9,adult  Bronchiectasis  Chronic pain syndrome  Chronic, continuous use of opioids  DDD (degenerative disc disease), lumbar  Decreased range of motion of shoulder  Depression  GERD (gastroesophageal reflux disease)  Hyperlipidemia  Hypertension  Impingement syndrome of right shoulder  Incontinence  Left shoulder pain  Long term use of drug  Lumbar radicular pain  Migraine  Migraines  Morbid obesity  OSA on CPAP  Osteoarthritis  Osteoarthritis of carpometacarpal (CMC) joint of left thumb  Palpitations  Situational depression  Type 2 diabetes mellitus with diabetic polyneuropathy  Procedure/Surgical History  ?Colonoscopy (06/20/2022) ?colonoscopy (02/05/2008) ?ablation ?ankles and feet ?cholecystectomy ?left elbow orif ?lobectomy ?TAH  Surgical History Internal  06/20/2022    Colonscpy Diagnostic/Screen     MD  Medications  Home Medications (19) Active Aldactone 25 mg oral tablet 25 mg = 1 Tablet, Orally, Daily cetirizine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily diclofenac 1% topical gel 2 GM, Topical, 4 Times Daily dicyclomine 10 mg oral capsule 10 mg = 1 Capsule, Orally, TID, Take 30 minutes before meals. Evista 60 mg oral tablet 60 mg = 1 Tablet, Orally, Daily FLUoxetine 20 mg oral capsule 20 mg = 1 Capsule, Orally, Daily hydrOXYzine hydrochloride 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, 4 Times Daily Lipitor 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily lisinopril 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily Neurontin 800 mg oral tablet 800 mg = 1 Tablet, Orally, 4 Times Daily, 1 in am, 1 in pm, 2 at bedtime Norco 10 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q4H, not to exceed 6 tablets/dayfill when due in June Protonix 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, BID SUMAtriptan 6 mg/0.5 ml subcutaneous solution 6 mg, Subcutaneous, ONCE, may repeat once in 1 hour if needed; dispense pre-filled syringe Symbicort 80 mCg-4.5 mCg/inh inhalation aerosol 2 Puff, Inhalation, BID Topamax 50 mg oral tablet 50 mg = 1 Tablet, Orally, QHS traZODONE 50 mg oral tablet 100 mg = 2 Tablet, Orally, At Bedtime Trelegy Ellipta 200 mCg-62.5 mCg-25 mCg inhalation powder 1 Puff, Inhalation, Daily Ventolin HFA 90 mCg/inh inhalation aerosol 2 Puff, PRN, Inhalation, Q4H Zofran ODT 4 mg oral tablet, disintegrating 4 mg = 1 Tablet, PRN, Orally, Q6H  Medication Administration   Given  acetaminophen, 1000 mg, Orally  aspirin, 324 mg, Orally  dicyclomine, 10 mg, Orally  droperidol, 2.5 mg, IV Push  magnesium sulfate, IVPB  morphine inj ED (doses 5 mg - 10 mg), 4 mg, IV Push  morphine inj ED (doses 5 mg - 10 mg), 4 mg, IV Push  ondansetron, 4 mg, IV Push  Tessalon Perles, 100 mg, Orally  Allergies   diphenhydrAMINE (sycope)  Nasal Spray (critical)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   single, 1 child   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Cancer of colon: Father.  Lung cancer..: Father.  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  05/25/23 22:44  15.6  High  05/13/23  12.8  High          RBC  05/25/23 22:44  4.20  05/13/23  4.54          Hgb  05/25/23 22:44  11.7  Low  05/13/23  12.6          Hct  05/25/23 22:44  36.3  05/13/23  38.9          MCV  05/25/23 22:44  86  05/13/23  86          MCH  05/25/23 22:44  27.9  05/13/23  27.9          MCHC  05/25/23 22:44  32.3  05/13/23  32.5          RDW  05/25/23 22:44  15.1  High  05/13/23  14.3          Platelet  05/25/23 22:44  281  05/13/23  360          MPV  05/25/23 22:44  8.1  05/13/23  7.2          Neutrophils %  05/25/23 22:44  90  05/13/23  84          Lymphocytes %  05/25/23 22:44  7  05/13/23  12          Monocytes %  05/25/23 22:44  2  05/13/23  4          Eosinophils %  05/25/23 22:44  0  05/13/23  0          Basophils %  05/25/23 22:44  0  05/13/23  0          Absolute Neutrophil  05/25/23 22:44  14.1  High  05/13/23  10.7  High          Absolute Lymphocyte  05/25/23 22:44  1.1  05/13/23  1.5          Absolute Monocyte  05/25/23 22:44  0.3  05/13/23  0.5          Absolute Eosinophil  05/25/23 22:44  0.0  05/13/23  0.0          Absolute Basophil  05/25/23 22:44  0.1  05/13/23  0.1           Routine Coagulation Studies FS  LATEST RESULTS  HISTORICAL RESULTS          PT  05/25/23 22:44  10.4  08/26/22  11.1          INR  05/25/23 22:44  0.92  08/26/22  0.97          D-Dimer Pl QN  05/25/23 22:44  645  High               Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  05/25/23 22:44  138  05/13/23  138          Potassium SerPl QN  05/25/23 22:44  3.7  05/13/23  3.8          Chloride SerPl QN  05/25/23 22:44  104  05/13/23  103          Carbon Dioxide SerPl QN  05/25/23 22:44  23  05/13/23  21  Low          Anion Gap  05/25/23 22:44  11  05/13/23  14  High          BUN SerPl QN  05/25/23 22:44  13  05/13/23  15          Creatinine SerPl QN  05/25/23 22:44  1.03  05/13/23  0.88          Estimated GFR (CKD-EPI, no race)  05/25/23 22:44  58  Low  05/13/23  70          Estimated CRCL (CG)  05/25/23 22:44  58  Low  05/13/23  66          Glucose SerPl QN  05/25/23 22:44  137  High  05/13/23  117  High          Calcium Total SerPl QN  05/25/23 22:44  8.8  05/13/23  9.9          Alkaline Phos SerPl QN  05/25/23 22:44  50  05/13/23  51          ALT SerPl QN  05/25/23 22:44  10  05/13/23  12          AST SerPl QN  05/25/23 22:44  13  05/13/23  15          Bilirubin Total SerPl QN  05/25/23 22:44  0.3  05/13/23  0.3          Total Protein SerPl QN  05/25/23 22:44  6.8  05/13/23  7.5          Albumin SerPl QN  05/25/23 22:44  4.0  05/13/23  4.5          Lipase SerPl QN  05/25/23 22:44  16  05/13/23  6  Low          Troponin-I High Sensitivity  05/25/23 22:44  25  High  03/18/22  20  High      Diagnostic Results  CT Abd/Pelvis W/IV Contrast    05/26/23 00:51:37  IMPRESSION:  CT Angiogram Chest:  1. No obvious pulmonary embolism.  2. Left basilar parenchymal scarring.  3. No airspace consolidation or pleural effusion.   CT Abdomen and Pelvis:  1. Mild circumferential wall thickening of the proximal sigmoid  colon may be secondary to underdistention however consider short  segment focal colitis in the correct clinical setting.  2. Scattered diverticulosis without CT evidence of acute  diverticulitis.  3. Dense stool throughout the left hemicolon. Consider constipation  in the correct clinical setting.  4. No high-grade small bowel obstruction or ascites.  5. Status post hysterectomy.  6. Status post cholecystectomy.   Thank you for consulting our team of subspecialty radiologists at Radiology.     Electronically Signed by:     Signed By:  MD     ************************************************** XR Chest PA or AP Portable    05/26/23 00:28:55  IMPRESSION:  1. Small left pleural effusion.  2. Central vascular congestion without overt pulmonary edema.   Thank you for consulting our team of subspecialty radiologists a Radiology.     Electronically Signed by:     Signed By: MD     ************************************************** CTA Chest Pulm Embolism W/IV Contrast    05/26/23 00:51:37  IMPRESSION:  CT Angiogram Chest:  1. No obvious pulmonary embolism.  2. Left basilar parenchymal scarring.  3. No airspace consolidation or pleural effusion.   CT Abdomen and Pelvis:  1. Mild circumferential wall thickening of the proximal sigmoid  colon may be secondary to underdistention however consider short  segment focal colitis in the correct clinical setting.  2. Scattered diverticulosis without CT evidence of acute  diverticulitis.  3. Dense stool throughout the left hemicolon. Consider constipation  in the correct clinical setting.  4. No high-grade small bowel obstruction or ascites.  5. Status post hysterectomy.  6. Status post cholecystectomy.   Thank you for consulting our team of subspecialty radiologists at Radiology.     Electronically Signed by:     Signed By:  MD      Signature Line Electronically Signed on 05/25/23 23:58 EDT ________________________________________________________    Electronically Signed on 05/26/23 01:59 EDT ________________________________________________________ MD