Age: 80.0
Sex: F
Vaccine: RSV
Symptoms: Glucose urine absent, Haematochezia, Haematocrit normal, Haemoglobin normal, Haemoglobin urine present
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on January 15, 2025 06:18 EST   Verified By: MD on January 15, 2025 06:18 EST   Encounter Info: Hospital, Inpatient, 01/15/25 -     * Final Report *        Chief Complaint   Vomiting and blood in stool     History of Present Illness/Subjective     Patient is an 80 year old woman w/ HTN who presents to the ER w/ bloody stool and vomiting. Patient states that she has been constipated for the last 9 days. Yesterday she noticed bright red blood in her stool when she was straining to use the bathroom. She also reports some vomiting. She has pain in her abd as well. Upon arrival to the ER her vitals notable for a BP of 149/61. Labs were notable for a WBC count of 13. K was 3.4. CT abd/pelvis showed a fluid filled appendix w/ multiple appendicoliths but no abscess or inflammation. Patient was given pain meds and fluids and admitted to the medicine service for further management.     Review of Systems     With the exception of that noted in the HPI all systems were reviewed and were negative.     Physical Exam/Objective Vitals & Measurements most recent past 24 hours      Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  CTAB Cardiovascular:  Regular rate and rhythm, no MGR Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect     Assessment/Plan      1. Abdominal pain   R10.9  -Possibly appendicitis although CT does not show this  -Dr. consult in the AM  -Zosyn for now      2. Hypokalemia   E87.6  -The patient presents with a electrolyte imbalance including hypokalemia.  Continue to trend serial analysis as appropriate with replenishment of electrolyte imbalance as required for stabilization.      3. Leukocytosis   D72.829  -Unclear cause but covering w/ Zosyn for now  -Daily CBC      4. Vomiting   R11.10  -No obvious obstruction on CT  -PRN anti-emetics  -Possible a viral gastroenteritis      5. Hypertension   I10  -Relatively normotensive and stable, continue to trend, continue home regimen with titration as appropriate      6. Hematochezia  -Possibly hemorrhoidal in nature  -Dr. consulted  -Hgb stable and c/f UGIB is low     Code Status  Full Code   Chronic Problem List    No qualifying data  Medications   Home Medications (8) Active  aspirin 81 mg oral capsule 81 mg = 1 Capsule, Orally, Q24H  atenolol 50 mg, Orally, Daily  buPROPion 12 hour extended release , Orally, BID  calcium (as carbonate) 600 mg oral tablet 1,200 mg = 2 Tablet, Orally, Daily  hydroCHLOROthiazide 25 mg, Orally, Daily  losartan 100 mg oral tablet 100 mg = 1 Tablet, Orally, Daily  Multi Vitamin+   Vitamin D3 25 mCg (1,000 intl units) oral capsule 25 mCg = 1 Capsule, Orally, Daily  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 01/14/25 00:00:00 TO 01/15/25 06:12:05  None Reported  PRN Medications (0600 - 0559) from 01/14 - 01/15  None Reported  Allergies   NKA  Social History    Electronic Cigarette/Vaping   E-Cigarette Use Never.   Sexual Orientation and Gender Identity   Which of the following do you identify most closely with? (check all that apply) Heterosexual (or straight). What is your current gender identity? (check all that apply) Female.   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Non-contributory  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 13.2 k/cumm High (01/14/25 22:27:00)  RBC: 4.23 million/cumm (01/14/25 22:27:00)  Hgb: 13.6 GM/dL (01/14/25 22:27:00)  Hct: 40.2 % (01/14/25 22:27:00)  MCV: 95 fL (01/14/25 22:27:00)  MCH: 32.2 pg (01/14/25 22:27:00)  MCHC: 33.9 GM/dL (01/14/25 22:27:00)  RDW: 13.6 % (01/14/25 22:27:00)  Platelet: 200 k/cumm (01/14/25 22:27:00)  MPV: 9.8 fL (01/14/25 22:27:00)  Neutrophils %: 87 % (01/14/25 22:27:00)  Lymphocytes %: 8 % (01/14/25 22:27:00)  Monocytes %: 5 % (01/14/25 22:27:00)  Eosinophils %: 0 % (01/14/25 22:27:00)  Basophils %: 0 % (01/14/25 22:27:00)  Absolute Neutrophil: 11.5 k/cumm High (01/14/25 22:27:00)  Absolute Lymphocyte: 1 k/cumm (01/14/25 22:27:00)  Absolute Monocyte: 0.6 k/cumm (01/14/25 22:27:00)  Absolute Eosinophil: 0 k/cumm (01/14/25 22:27:00)  Absolute Basophil: 0.1 k/cumm (01/14/25 22:27:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (01/14/25 22:27:00)  Potassium SerPl QN: 3.4 mmol/L Low (01/14/25 22:27:00)  Chloride SerPl QN: 98 mmol/L (01/14/25 22:27:00)  Carbon Dioxide SerPl QN: 26 mmol/L (01/14/25 22:27:00)  Anion Gap: 11 mmol/L (01/14/25 22:27:00)  BUN SerPl QN: 14 mg/dL (01/14/25 22:27:00)  Creatinine SerPl QN: 0.86 mg/dL (01/14/25 22:27:00)  Estimated GFR (CKD-EPI, no race): 68 mL/min/1.73m2 (01/14/25 22:27:00)  Estimated CRCL (CG): 45 mL/min Low (01/14/25 22:27:00)  Glucose SerPl QN: 136 mg/dL High (01/14/25 22:27:00)  Calcium Total SerPl QN: 9.4 mg/dL (01/14/25 22:27:00)  Alkaline Phos SerPl QN: 62 Units/L (01/14/25 22:27:00)  ALT SerPl QN: 17 Units/L (01/14/25 22:27:00)  AST SerPl QN: 24 Units/L (01/14/25 22:27:00)  Bilirubin Total SerPl QN: 0.5 mg/dL (01/14/25 22:27:00)  Total Protein SerPl QN: 6.8 GM/dL (01/14/25 22:27:00)  Albumin SerPl QN: 4.3 GM/dL (01/14/25 22:27:00)  Troponin-I High Sensitivity: 3 ng/L (01/14/25 22:27:00)  Coagulation:  PT: 14.1 seconds High (01/14/25 22:27:00)  INR: 1.22 (01/14/25 22:27:00)  Urine Studies:  Color: Yellow (01/14/25 23:34:00)  Clarity: Clear (01/14/25 23:34:00)  Specific Gravity: 1.03 (01/14/25 23:34:00)  pH: 6 (01/14/25 23:34:00)  Protein: 20 Abnormal (01/14/25 23:34:00)  Glucose: Normal (01/14/25 23:34:00)  Ketones: 150 Abnormal (01/14/25 23:34:00)  Bilirubin: NEGATIVE (01/14/25 23:34:00)  Hgb Ur: Small 1+ Abnormal (01/14/25 23:34:00)  Nitrite: NEGATIVE (01/14/25 23:34:00)  Urobilinogen: Normal (01/14/25 23:34:00)  Leukocyte Esterase Ur: Small75 Abnormal (01/14/25 23:34:00)  WBC: 0-5 (01/14/25 23:34:00)  RBC: 11-20 Abnormal (01/14/25 23:34:00)  Bacteria: NONE (01/14/25 23:34:00)  Squamous Epithelial: Few (01/14/25 23:34:00)  Hyaline Casts: 0-2 (01/14/25 23:34:00)  Misc UA Micro: Misc UA Micro (01/14/25 23:34:00)  All Other Labs:  Specimen Type Occult Blood: Stool (01/15/25 01:25:00)  Occult Blood Stool: Negative (01/15/25 01:25:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 01/14/2025 08:27 - XR Wrist 3 View Right  IMPRESSION: 1.  Healing, mildly impacted and angulated fracture of the distalright radius.2.  Old fracture deformities of the distal right radius and ulna.3.  Osteoarthrosis of the first carpometacarpal joint.    01/15/2025 01:59 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  The appendix is dilated and fluid-filled with multiple calcifiedappendicoliths in the lumen. No obvious periappendiceal inflammatorychange. Negative for periappendiceal abscess. Findings are equivocalfor early acute appendicitis. Recommend correlation with physicalexam and laboratory values.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us at XXX-XXX-XXXX(XXX-XXX-XXX) with any questions.             Signature Line Electronically Signed on 01/15/25 06:18 EST ________________________________________________________ MD