Age: 54.0
Sex: F
Vaccine: COVID19
Symptoms: Dehydration, Differential white blood cell count, Dizziness, Dyspepsia, Dyspnoea
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: DO on December 12, 2022 00:58 EST   Verified By: DO on December 12, 2022 00:58 EST   Encounter Info: Hospital, Observation, 12/11/22 -     * Final Report *        Chief Complaint   vomiting  History of Present Illness/Subjective     Patient presented to hospital ED due to vomiting that began today. Patient is concerned that the vomitus appeared to be mixed with dark red material and given that she has also been dealing with chronic lower gi bleeding with a c-scope scheduled with Dr. next month she was concerned enough to come in. She also endorses SOB, dizziness. She denies CP, syncope, abd pain, dysuria. Denies blood thinners or history of upper GI bleeding prior.   Add'l medical hx includes: HTN, HLD, psoriatic arthritis, IBS, Gilberts syndrome, hypothyroid, breast ca Social hx:  former smoker   In the ED patient met sirs criteria for sepsis cultures sent and abx started, patient incidentally tested positive for covid though other than some transient hypoxia is asymptomatic, she also had a UA positive for uti. She improved with ivf, We will place her in obs and transition to oral abx tomorrow if improving. Will also obtain gi consultation from Dr. in the am   Note, per chart review, patient has a hx of pyelnephritis.  Review of Systems     A complete, 13-system review was performed and was negative except for as noted in the HPI.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 37.2 (36.3-37.2)  Temp (FAHR) 99.0 (97.3-99.0), BP 140/65 (140-173)/(65-92), HR 89 (84-111), RR 18 (18-24), O2Sat 90 (90-90) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    76 kg    12/11/22  Previous Daily Weight:    76 kg    12/11/22  BMI:    27.9    12/11/22    Overweight (BMI 25-29.9) Patient Height  Current Height:    165.1 cm    12/11/22        Constitutional:  No acute distress,  well-nourished Eyes:  PERRL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs have scattered crackles b/l in bases no wheezes, sat 93% on RA while in bed Cardiovascular:  Regular rate and rhythm, no murmurs appreciated Gastrointestinal:  Soft, non-tender, non-distended, rectal exam declined Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  Assessment/Plan      1. Nausea & vomiting   R11.2  zofran prn  monitor qtc  possibly 2/2 uti vs covid vs dyspepsia vs other  given patient noted some dark red material in her vomit will obtain gi consultation in the am and start pantoprazole 40mg iv bid and keep on cld   2. Sepsis   A41.9  likely 2/2 uti vs covid component, bacterial pna less likely  sepsis now resolved after iv fluid admin, dehydration more likely culprit of initial tachycardia  follow cultures, trend lactate until normalized   3. UTI (urinary tract infection)   N39.0  follow culture  rocephin  monitor urine output  due to hx of nephrolithiasis and pyelonephritis, will obtain a renal/bladder us however nothing to suggest obstructive uropathy or pyelonephritis at present time   4. COVID-19   U07.1  mild  remdesivir  resp eval and svns prn  fluticasone inhaler   5. Dehydration   E86.0  cont iv fluids   6. Chronic lower GI bleeding   K92.2  see plan for #1  patient was scheduled for c-scope in january, will see if Dr. would like to do c-scope while here   7. Hyperglycemia   R73.9  cont to monitor with accuchecks q12  hx of prediabetes will obtain a1c   8. Chronic GERD   K21.9  see above   9. Hyperlipidemia   E78.5   10. Hypothyroidism   E03.9   11. Irritable bowel syndrome with diarrhea   K58.0   12. Nephrolithiasis   N20.0   13. Psoriatic arthritis   L40.50   14. Gilbert's syndrome   E80.4  noted. cont home medications as appropriate   Orders:   acetaminophen, 650 mg, Orally, Tablet, Q6H, PRN, Fever/Pain, Mild (1-3 out of 10), 12/12/22 0:03:00 EST  albuterol-ipratropium, 3 mL, Neb Inhal, Inhalation SOLN, Aerosol Treatment, Q6H, PRN, Shortness of Breath/Wheezing, 12/12/22 0:02:00 EST  ceftRIAXone, 1 GM, IVPB, Injection, Q24H, 12/12/22 19:00:00 EST, 12/12/22 19:00:00 EST, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  fluticasone, 2 Puff, Inhalation, Aerosol, MDI/DPI Inhaler Treatment, BID, 12/12/22 9:00:00 EST, for 7 Days, 12/18/22 21:00:00 EST  Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 12/12/22 0:02:00 EST, 100 mL/hr, Clinical Weight  morphine, 2 mg, IV Push, Injection, Q4H, PRN, Pain Severe IV (7-10 out of 10), 12/12/22 0:02:00 EST  ondansetron, 4 mg, IV Push, Injection, Q6H, PRN, Nausea/Vomiting IV - Use First, 12/12/22 0:02:00 EST  pantoprazole, 40 mg, IV Push, Injection, BID, 12/12/22 9:00:00 EST  remdesivir, 100 mg, IVPB, Injection, At Bedtime, 12/12/22 21:00:00 EST, for 4 Doses, 12/15/22 21:00:00 EST, 500 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 250  remdesivir, 200 mg, IVPB, Injection, ONCE, 12/12/22 1:00:00 EST, 12/12/22 1:00:00 EST, 500 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 250  Assign To  Auto Diff  Bladder Scan  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Oxygen Need Greater Than  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  CBC w/Differential  CBC w/Differential  Clear Liquid no Red or Purple Diet  Comp Metabolic Panel  Comp Metabolic Panel  DC SIRS Alert and Sepsis Screen  Do Not (Specify)  Gluc-Strip POC  Hgb A1C HPLC Bld QN  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  L pneumophila Ag Ur QL  Lactate Pl Venous QN  Level of Care  Lipid Panel SerPl QN  Magnesium SerPl QN  Magnesium SerPl QN  Medical Service  Peripheral IV Insertion  Procalcitonin  Reason for Not Ordering Medication Prophylaxis  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  Strep pneumoniae Ag Urine  Telemetry Class III 24hr Recommendation  TSH w FreeT4 reflex  Urine CX  US Renal and Bladder  Vital Signs  Vital Signs  Weight  Weight   Code Status   Resuscitation Status - Ordered    -- 12/12/22 0:02:00 EST, Full Code   Chronic Problem List    Breast cancer  Chronic GERD  Degenerative arthritis of ankle  Depressive disorder  Diarrhea  Diverticulosis  Gilbert's syndrome  Hyperlipidemia  Hypothyroidism  Irritable bowel syndrome with diarrhea  Multiple joint pain  Nephrolithiasis  PA (psoriatic arthritis)  Prehypertension  Rectal bleeding  Trochanteric bursitis  Weight gain  Procedure/Surgical History  ?Kidney Stone Removal (09/27/2020) ?colonoscopy (11/07/2017) ?egd (11/07/2017) ?Lumpectomy (07/01/2015) ?uterine ablation (2014) ?EGD and Colonoscopy w/ antrum and colon polyp from sigmoid bx (01/23/2007) ?Colonoscopy (2004) ?Dilation and Curettage (2002) ?Carpal Tunnel Repair (1992) ?back surgery for scoliosis and low grade spinal bifida (1979) ?ovaries removed ?Removal of both fallopian tubes ?Sling procedure of bladder neck  ?oophorectomy-left  Surgical History Internal  09/03/2020    Ureteroscopy.  (Right)   MD  08/27/2020    Cystoscopy Insert Ureteral Stent or Cath  (Right)   MD  08/05/2015    Breast Axillary Excision Biopsy  (Left)   MD  07/07/2015    Breast Excision Biopsy  (Left)   MD  Medications   Home Medications (17) Active  alendronate 35 mg oral tablet 35 mg = 1 Tablet, Orally, Weekly, with 6-8 oz plain water, at least 30 minutes before first food, beverage, or medication of the day.  aripiprazole 5 mg oral tablet See Instructions, 1/2  Tablet Orally Daily  Calcium 500+D 1 Tablet, Orally, QAM  chromium picolinate 1 Tablet, Orally, QAM  Colestid 1 g oral tablet 1 GM = 1 Tablet, PRN, Orally, BID, Take 1 tablet 1 to 2 times daily  desvenlafaxine 100 mg oral tablet, extended release 100 mg = 1 Tablet, Orally, QAM  Fish Oil 1,000 mg, Orally, QAM  folic acid 1 mg oral tablet 1 mg = 1 Tablet, Orally, QAM  GaviLyte-G oral powder for reconstitution See Instructions, as directed  letrozole 2.5 mg oral tablet 1 Tablet, Orally, Daily  levothyroxine 100 mCg (0.1 mg) oral tablet 100 mCg = 1 Tablet, Orally, QAM  metoPROLOL succinate 50 mg oral tablet, extended release 50 mg = 1 Tablet, Orally, QAM  nitroGLYCerin 0.4 mg sublingual tablet 0.4 mg = 1 Tablet, PRN, Sublingually, Q5min  prazosin 2 mg oral capsule 4 mg = 2 Capsule, Orally, QHS  Viberzi 100 mg oral tablet 100 mg, Orally, BID  Vitamin B-12 500 mCg, Orally  vitamin E 400 intl units oral capsule 400 IntlUnits = 1 Capsule, Orally, Daily  Active Scheduled Inpatient Medications  ceftRIAXone, Injection, 1 GM, IVPB, Q24H, Start: 12/12/22 19:00:00  fluticasone (fluticasone HFA 220 mCg/inh), Aerosol, 2 Puff, Inhalation, BID, Start: 12/12/22 09:00:00  pantoprazole, Injection, 40 mg, IV Push, BID, Start: 12/12/22 09:00:00  remdesivir, Injection, 200 mg, IVPB, ONCE, Start: 12/12/22 01:00:00  remdesivir, Injection, 100 mg, IVPB, At Bedtime, Start: 12/12/22 21:00:00  Lactated Ringers  1,000 mL IV  100 mL/hr       One-Time Medications Given 12/11/22 00:00:00 TO 12/12/22 00:36:33  ceftRIAXone, Injection, 1 GM, IV Push, ONCE, (1 DOSE 12/11/22 19:17:00)  droperidol, Injection, 1.25 mg, IV Push, ONCE, (1 DOSE 12/11/22 21:34:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, prn, Nausea/Vomiting IV - Use First, (1 DOSE 12/11/22 17:46:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 12/11/22 20:57:00)  promethazine, Injection, 25 mg, IVPB, ONCE, (1 DOSE 12/11/22 19:17:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 12/11/22 19:17:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 12/11/22 20:57:00)  PRN Medications (0600 - 0559) from 12/11 - 12/12  acetaminophen, 650 mg, Orally, Q6H, 0  Dose(s)   albuterol-ipratropium, 3 mL, Neb Inhal, Q6H, 0  Dose(s)   morphine, 2 mg, IV Push, Q4H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q6H, 1  Dose(s)   Allergies   Duragesic (unknown)  tricyclic antidepressants (unknown)  Butrans (Unknown)  CeleBREX (Unknown)  Cymbalta (Weight Gain, Anxiety)  Ibu (Unknown)  Suboxone (Unknown)  Vicodin (Unknown)  Voltaren (Unknown)  Wellbutrin (Anxiety)  carisoprodol (Unknown)  codeine (Unknown)  cyclobenzaprine (Unknown)  fentaNYL (Unknown)  meloxicam (Unknown)  meperidine (Unknown)  methadone (Unknown)  methotrexate (Rash and vomiting)  naltrexone (Unknown)  oxyCODONE (Unknown)  sulfa drugs (Nausea)  tetracyclic antidepressants (Unknown)  traMADol (Unknown)  Social History    Alcohol   Current, 1-2 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Cancer involving organ by direct extension from uterine cervix: Mother.  Cancer of colon: Father.  Lung cancer..: Grandmother.  Throat: Aunt.  Thyroid: Brother.  Thyroid cancer: Brother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 9.4 k/cumm (12/11/22 17:45:00)  RBC: 5.27 million/cumm High (12/11/22 17:45:00)  Hgb: 17.4 GM/dL High (12/11/22 17:45:00)  Hct: 50.8 % High (12/11/22 17:45:00)  MCV: 97 fL (12/11/22 17:45:00)  MCH: 33 pg (12/11/22 17:45:00)  MCHC: 34.2 GM/dL (12/11/22 17:45:00)  RDW: 13.4 % (12/11/22 17:45:00)  Platelet: 295 k/cumm (12/11/22 17:45:00)  MPV: 7.8 fL (12/11/22 17:45:00)  Neutrophils %: 60 % (12/11/22 17:45:00)  Lymphocytes %: 34 % (12/11/22 17:45:00)  Monocytes %: 6 % (12/11/22 17:45:00)  Eosinophils %: 0 % (12/11/22 17:45:00)  Basophils %: 0 % (12/11/22 17:45:00)  Absolute Neutrophil: 5.7 k/cumm (12/11/22 17:45:00)  Absolute Lymphocyte: 3.2 k/cumm (12/11/22 17:45:00)  Absolute Monocyte: 0.6 k/cumm (12/11/22 17:45:00)  Absolute Eosinophil: 0 k/cumm (12/11/22 17:45:00)  Absolute Basophil: 0 k/cumm (12/11/22 17:45:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (12/11/22 17:45:00)  Potassium SerPl QN: 4.2 mmol/L (12/11/22 17:45:00)  Chloride SerPl QN: 100 mmol/L (12/11/22 17:45:00)  Carbon Dioxide SerPl QN: 20 mmol/L Low (12/11/22 17:45:00)  Anion Gap: 19 mmol/L High (12/11/22 17:45:00)  BUN SerPl QN: 23 mg/dL High (12/11/22 17:45:00)  Creatinine SerPl QN: 0.93 mg/dL (12/11/22 17:45:00)  Estimated GFR (CKD-EPI, no race): 73 mL/min/1.73m2 (12/11/22 17:45:00)  Estimated CRCL (CG): 70 mL/min (12/11/22 17:45:00)  Glucose SerPl QN: 141 mg/dL High (12/11/22 17:45:00)  Calcium Total SerPl QN: 9.1 mg/dL (12/11/22 17:45:00)  Alkaline Phos SerPl QN: 101 Units/L (12/11/22 17:45:00)  ALT SerPl QN: 72 Units/L High (12/11/22 17:45:00)  AST SerPl QN: 58 Units/L High (12/11/22 17:45:00)  Bilirubin Total SerPl QN: 1 mg/dL (12/11/22 17:45:00)  Total Protein SerPl QN: 6.9 GM/dL (12/11/22 17:45:00)  Albumin SerPl QN: 4.5 GM/dL (12/11/22 17:45:00)  Lipase SerPl QN: 76 Units/L High (12/11/22 17:45:00)  Troponin-I High Sensitivity: 7 ng/L (12/11/22 19:32:00)  BNP Pl QN: 14 pg/mL (12/11/22 18:51:00)  Lactate Venous Pl QN: 3.5 mmol/L High (12/11/22 21:20:00)  Coagulation:  PT: 13.4 seconds (12/11/22 17:45:00)  INR: 1.17 (12/11/22 17:45:00)  D-Dimer Pl QN: <200 (12/11/22 18:51:00)  Urine Studies:  Color: Yellow (12/11/22 19:20:00)  Clarity: Clear (12/11/22 19:20:00)  Specific Gravity: >=1.030 (12/11/22 19:20:00)  pH: 5.5 (12/11/22 19:20:00)  Protein: NEGATIVE (12/11/22 19:20:00)  Glucose: NEGATIVE (12/11/22 19:20:00)  Ketones: NEGATIVE (12/11/22 19:20:00)  Bilirubin: NEGATIVE (12/11/22 19:20:00)  Hgb Ur: TRACE. Abnormal (12/11/22 19:20:00)  Nitrite: POSITIVE Abnormal (12/11/22 19:20:00)  Urobilinogen: NormalUro (12/11/22 19:20:00)  Leukocyte Esterase Ur: TRACE. Abnormal (12/11/22 19:20:00)  WBC: 11-20 Abnormal (12/11/22 19:20:00)  RBC: 3-5 Abnormal (12/11/22 19:20:00)  Bacteria: Few Abnormal (12/11/22 19:20:00)  Squamous Epithelial: Few (12/11/22 19:20:00)  Mucous: PRESENT. (12/11/22 19:20:00)  Toxicology:  Amphetamine Urine Scn QL: Negative (12/11/22 19:20:00)  Methamphetamine Urine Scn QL: Negative (12/11/22 19:20:00)  Barbiturates Urine Scn QL: Negative (12/11/22 19:20:00)  Benzodiazepines Urine Scn QL: Negative (12/11/22 19:20:00)  Cannabinoid Urine Scn QL: Negative (12/11/22 19:20:00)  Cocaine Urine Scn QL: Negative (12/11/22 19:20:00)  Opiates Urine Scn QL: Negative (12/11/22 19:20:00)  PCP Urine Scn QL: Negative (12/11/22 19:20:00)  Methadone Urine Scn QL: Negative (12/11/22 19:20:00)  Propoxyphene Urine Scn QL: Negative (12/11/22 19:20:00)  Oxycodone Urine Scn QL: Negative (12/11/22 19:20:00)  Buprenorphine Urine Scn QL: Negative (12/11/22 19:20:00)  Tricyclic Antid Urine Scn QL: Negative (12/11/22 19:20:00)  Drugs of Abuse Comment: See Comment (12/11/22 19:20:00)  Ethanol Pl QN: 94 mg/dL (12/11/22 19:32:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (12/11/22 17:51:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (12/11/22 17:51:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (12/11/22 17:51:00)  Rapid Influenza A PCR: Not Detected (12/11/22 17:51:00)  Rapid Influenza B PCR: Not Detected (12/11/22 17:51:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 12/11/2022 19:11 - XR Chest PA or AP  IMPRESSION: No acute findings. Thank you for consulting with Radiology. Healthcare providers wishing to discuss this case further can contact the ER Reading Room.                Signature Line Electronically Signed on 12/12/22 00:58 EST  DO