Age: 38.0
Sex: F
Vaccine: COVID19
Symptoms: Protein total normal, Red blood cell count normal, Red cell distribution width normal, Scan with contrast abnormal, Splenomegaly
Clinical narrative: Document Type: Primary Care OP Provider Note   Document Subject: Primary Care Progress Note   Performed By: NP on July 18, 2022 05:49 EDT   Verified By: NP on July 18, 2022 05:49 EDT   Encounter Info: Clinic, 06/29/22 - 06/29/22    * Final Report *        Chief Complaint   Patient is here today to discuss a ulcer - discuss meds - swollen ankles  History of Present Illness/Subjective     39 y/o female here today with c/o of pressure in upper R quad for almost a full month. She bent down and it has been more uncomfortable since then. She saw an urgent care clinic when the pressure progressed to pain and was started on Carafate and famotidine. She is taking the famotidine daily and uses the Carafate PRN (typically a time or two a day). She does not notice a difference with an empty or full stomach or the pain associated with eating. Pain does not radiate. Denies n/v. Hx of GERD but states symptoms do not feel the same. No hx of ulcer.    She also complains of bilateral lower leg swelling and is concerned her BP has been running high. She denies any HA or visual changes.  Review of Systems     Constitutional:  Negative, No weakness, No fatigue, No decreased activity.   Eye:  Negative.   Ear/Nose/Mouth/Throat:  Negative.   Respiratory:  Negative.   Cardiovascular:  Negative.   Gastrointestinal:  See HPI   Hematology/Lymphatics:  Negative.   Endocrine:  Negative.   Immunologic:  Negative.   Musculoskeletal:  Negative.   Integumentary:  Negative.   Neurologic:  Negative.   Psychiatric:  No anxiety, No depression.   All other systems are negative   Health Status     Depression Screening  Depression Screen PHQ9 Total: 2 (06/29/22 10:28:00)  Initial Depression Screen Score: 0 (06/29/22 10:28:00)    Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Heart Rate:       103 bpm  BP #1:       138 / 90 mmHg  SpO2 (%):       98 %     No qualifying data available.      General:  Alert and oriented, No acute distress.   Eye:  Pupils are equal, round and reactive to light, Normal conjunctiva.   HENT:  Normocephalic, Tympanic membranes are clear.   Neck:  Non-tender, No carotid bruit, No jugular venous distention, No lymphadenopathy, No thyromegaly. Cardiovascular:  Regular rate, Normal rhythm, S1, S2.   Respiratory:  Lungs are clear to auscultation, Respirations are non-labored.   Gastrointestinal:  Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly.   Integumentary:  Warm, Dry, Intact.   Neurologic:  Alert, Oriented, Normal sensory, Normal motor function, No focal defects, Cranial Nerves II-XII are grossly intact.   Psychiatric:  Cooperative, Appropriate mood & affect.                    Assessment/Plan       1. Abdominal pain   R10.9  Continue the daily famotidine and Carafate. Use Carafate at least 3 to 4 times daily. If symptoms do not improve in the next 3 weeks will consider EGD if needed.  Pt agreed on POC.  If symptoms worse will refer for scope.    Ordered:   CHARGE 99214 OV Est Extend 30-39 min     2. Edema   R60.9  start medication as directed.  low sodium diet encouraged.  Compression stockings and increase walking.   Monitor BP at home and log results.   Ordered:   CHARGE 99214 OV Est Extend 30-39 min       Chronic Problem List    Abdominal pain  Blood pressure check  Calcaneal bursitis, left  Edema  Encounter for weight loss counseling  Follicular neoplasm of thyroid  Heel pain, chronic  Obesity  OSA (obstructive sleep apnea)  Plantar fasciitis, left  Skin tag  Thyroid nodule  Thyromegaly  Tonsillar hypertrophy  Tonsillolith  Weight gain  Weight loss counseling, encounter for  Wellness examination  Procedure/Surgical History  ?Bunionectomy ?LAP-BAND surgery status ?partial right thyroid removal ?Tonsillectomy ?wisdom tooth extraction   Surgical History Internal  06/01/2018    Cholecystectomy Laparoscopic    MD  05/18/2018    ERCP Sphincterotomy Pappillotomy    MD  Medications  Home Medications (9) Active Adipex-P 37.5 mg oral tablet 37.5 mg = 1 Tablet, Orally, Daily Aleve 220 mg, Orally, Q8H hydroCHLOROthiazide 12.5 mg oral tablet 12.5 mg = 1 Tablet, Orally, Daily levothyroxine 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, Daily metFORMIN 500 mg oral tablet 500 mg = 1 Tablet, Orally, BID Misc Supplies See Instructions, BP monitor multivitamin 1 Tablet, Orally, Daily Prevacid 30 mg oral delayed release capsule 30 mg = 1 Capsule, Orally, BID Zyrtec 10 mg, Orally, Daily  Allergies   Latex (Hives)  No Known Medication Allergies  Social History    Alcohol   Current, Wine, Liquor   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Employed, Work/School description: works for Well point at home.   Home/Environment   married, 1 child, Lives with Children, Spouse.   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   DM (diabetes mellitus)...: Mother.  HTN (hypertension)...: Father.  Kidney failure...: Mother.  Narcolepsy...: Father.  Review Management   Lab Results     WBC: 6.6 k/cumm (07/06/22)  RBC: 4.93 million/cumm (07/06/22)  Hgb: 13.7 GM/dL (07/06/22)  Hct: 41.6 % (07/06/22)  MCV: 84 fL (07/06/22)  MCH: 27.7 pg (07/06/22)  MCHC: 32.8 GM/dL (07/06/22)  RDW: 13.8 % (07/06/22)  Platelet: 307 k/cumm (07/06/22)  MPV: 7.7 fL (07/06/22)  Neutrophils %: 56 % (07/06/22)  Lymphocytes %: 33 % (07/06/22)  Monocytes %: 7 % (07/06/22)  Eosinophils %: 3 % (07/06/22)  Basophils %: 1 % (07/06/22)  Absolute Neutrophil: 3.7 k/cumm (07/06/22)  Absolute Lymphocyte: 2.2 k/cumm (07/06/22)  Absolute Monocyte: 0.5 k/cumm (07/06/22)  Absolute Eosinophil: 0.2 k/cumm (07/06/22)  Absolute Basophil: 0 k/cumm (07/06/22)  Sodium SerPl QN: 142 mmol/L (07/06/22)  Potassium SerPl QN: 4.4 mmol/L (07/06/22)  Chloride SerPl QN: 105 mmol/L (07/06/22)  Carbon Dioxide SerPl QN: 28 mmol/L (07/06/22)  Anion Gap: 9 mmol/L (07/06/22)  BUN SerPl QN: 13 mg/dL (07/06/22)  Creatinine SerPl QN: 0.83 mg/dL (07/06/22)  Estimated GFR (CKD-EPI): 89 mL/min/1.73m2 (07/06/22)  Estimated CRCL (CG): >120 (07/06/22)  Glucose SerPl QN: 102 mg/dL High (07/06/22)  Calcium Total SerPl QN: 9.6 mg/dL (07/06/22)  Alkaline Phos SerPl QN: 77 Units/L (07/06/22)  ALT SerPl QN: 21 Units/L (07/06/22)  AST SerPl QN: 13 Units/L (07/06/22)  Bilirubin Total SerPl QN: 0.8 mg/dL (07/06/22)  Total Protein SerPl QN: 6.7 GM/dL (07/06/22)  Albumin SerPl QN: 4.2 GM/dL (07/06/22)  Cholesterol SerPl QN: 182 mg/dL (07/06/22)  Triglyceride SerPl QN: 146 mg/dL (07/06/22)  HDL SerPl QN: 38 mg/dL Low