Age: 57.0
Sex: F
Vaccine: COVID19
Symptoms: Hypokalaemia, Hypophosphataemia, Immature granulocyte count, Impaired driving ability, Insulin therapy
Clinical narrative: Date of Service Aug-04-2022 0636  Date of Admission Admit Date: Jul-31-2022  Date of Discharge Date of discharge Aug-04-2022  Allergies SEASONAL ALLERGIES - Not Specified  Chief Complaint Hyperglycemia and acidosis  Final Diagnoses Hyperglycemia  Procedure(s) Performed None  Lab Results Aug-04-2022 1146 GLUSTX  290 Aug-04-2022 0511 GLUSTX  169 Aug-04-2022 0500 Hematology WBC  6.3RBC  4.43HGB  14.2HCT  39.0MCV  88.0MCH  32.1MCHC  36.4RDW  13.8RDWSD  44.8PLT  130MPV  12.3AUTONEU%  81.6AUTOLYM%  9.5AUTOMON%  7.4AUTOEOS%  0.2AUTOBAS%  0.3AUTONEU#  5.2AUTOLYM#  0.6AUTOMON#  0.5AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  2.7IG#  0.06IG%  1.0 Aug-04-2022 0500 Chemistry GLUCOSE  170BUN  4CREAT  0.4MDRD GFR  164NA  140K  2.9CL  105CALCIUM  8.0CO2  26.0OSMO  280.3ANION GP  11.9BUN/CRE  10.0MAGNESIU  2.2PHOSPHOR  2.1 Aug-04-2022 0500 Serology PROCALC  <0.05 Aug-03-2022 2121 GLUSTX  181 Aug-03-2022 1946 GLUSTX  187 Aug-03-2022 1641 GLUSTX  201 Aug-03-2022 1453 GLUSTX  235 Aug-03-2022 1420 Chemistry PHOSPHOR  2.2 Aug-03-2022 1129 GLUSTX  219 Aug-03-2022 0923 GLUSTX  196 Aug-03-2022 0435 Serology PROCALC  <0.05 Aug-03-2022 0435 Hematology WBC  2.9RBC  4.23HGB  13.6HCT  37.1MCV  87.7MCH  32.2MCHC  36.7RDW  14.0RDWSD  45.1PLT  106MPV  12.5AUTONEU%  59.5AUTOLYM%  23.4AUTOMON%  13.6AUTOEOS%  0.7AUTOBAS%  0.7AUTONEU#  1.7AUTOLYM#  0.7AUTOMON#  0.4AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  2.7IG#  0.06IG%  2.1 Aug-03-2022 0435 Chemistry GLUCOSE  246BUN  3CREAT  0.6MDRD GFR  103NA  139K  3.2CL  106CALCIUM  7.6CO2  24.2OSMO  282.3ANION GP  12.0BUN/CRE  5.0CRP  2.40MAGNESIU  2.3PHOSPHOR  1.4 Aug-02-2022 1635 Chemistry GLUCOSE  213BUN  4CREAT  0.6MDRD GFR  103NA  139K  3.5CL  107CALCIUM  8.3CO2  20.9OSMO  280.8ANION GP  14.6BUN/CRE  6.7 Aug-02-2022 1400 Microbiology C SPUT  Klebsiella pneumoniae Aug-02-2022 1310 Chemistry GLUCOSE  354BUN  6CREAT  0.6MDRD GFR  103NA  136K  3.7CL  106CALCIUM  8.6CO2  17.2OSMO  283.8ANION GP  16.5BUN/CRE  10.0 Aug-02-2022 0905 Chemistry GLUCOSE  349BUN  5CREAT  0.6MDRD GFR  103NA  136K  4.2CL  105CALCIUM  8.3CO2  14.8OSMO  283.1ANION GP  20.4BUN/CRE  8.3 Aug-02-2022 0533 Blood Gas PH VEN  7.310PCO2 VEN  36.4PO2 VEN  57.0BICARB V  17.6BE VEN  -7.6CO2 CT V  16.0O2 SAT V  92.4 Aug-01-2022 0854 Chemistry GLUCOSE  306BUN  9CREAT  0.9MDRD GFR  64NA  135K  3.4CL  108CALCIUM  8.6CO2  15.6OSMO  280.3ANION GP  14.8BUN/CRE  10.0 Aug-01-2022 0803 GLUSTX  279 Aug-01-2022 0700 GLUSTX  300 Aug-01-2022 0616 GLUSTX  274 Aug-01-2022 0534 Serology PROCALC  <0.05 Aug-01-2022 0534 Hematology WBC  6.8RBC  4.61HGB  14.6HCT  40.5MCV  87.9MCH  31.7MCHC  36.0RDW  13.7RDWSD  43.9PLT  163MPV  11.5AUTONEU%  74.9AUTOLYM%  15.1AUTOMON%  8.1AUTOEOS%  0.1AUTOBAS%  0.3AUTONEU#  5.1AUTOLYM#  1.0AUTOMON#  0.6AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  2.8IG#  0.10IG%  1.5 Aug-01-2022 0534 Chemistry GLUCOSE  289BUN  12CREAT  0.9MDRD GFR  64NA  136K  4.0CL  108CALCIUM  8.9CO2  16.2OSMO  282.3ANION GP  15.8BUN/CRE  13.3TRIG  204CHOL  220LDL CALC  141HDL CHOL  38REL RISK  5.8LDL/HDLD  3.72CRP  0.60LIPASE  603MAGNESIU  1.9PHOSPHOR  0.9 Aug-01-2022 0534 Blood Gas PH VEN  7.210PCO2 VEN  34.7PO2 VEN  37.0BICARB V  13.3BE VEN  -13.6CO2 CT V  12.3O2 SAT V  82.2 Aug-01-2022 0525 GLUSTX  270 Aug-01-2022 0421 GLUSTX  295 Aug-01-2022 0347 GLUSTX  235 Aug-01-2022 0311 GLUSTX  149 Aug-01-2022 0215 GLUSTX  184 Aug-01-2022 0105 GLUSTX  205 Aug-01-2022 0041 Chemistry GLUCOSE  201BUN  13CREAT  0.9MDRD GFR  64NA  138K  3.2CL  108CALCIUM  8.9CO2  14.5OSMO  281.5ANION GP  18.7BUN/CRE  14.4 Aug-01-2022 0008 GLUSTX  225 Jul-31-2022 2259 GLUSTX  266 Jul-31-2022 2201 GLUSTX  286 Jul-31-2022 2056 GLUSTX  293 Jul-31-2022 2042 Chemistry GLUCOSE  303BUN  16CREAT  1.0MDRD GFR  57NA  137K  3.7CL  106CALCIUM  9.1CO2  11.9OSMO  286.4ANION GP  22.8BUN/CRE  16.0 Jul-31-2022 2001 GLUSTX  305 Jul-31-2022 1856 GLUSTX  323 Jul-31-2022 1759 GLUSTX  348 Jul-31-2022 1703 GLUSTX  411 Jul-31-2022 1640 Chemistry GLUCOSE  452BUN  19CREAT  1.1MDRD GFR  51NA  139K  2.8CL  106CALCIUM  9.1CO2  10.6OSMO  299.4ANION GP  25.2BUN/CRE  17.3TRIG  400LACTATE  1.90LIPASE  2870 Jul-31-2022 1640 Blood Gas PH VEN  7.05PCO2 VEN  34.0PO2 VEN  29.0BICARB V  9.0BE VEN  -22.1CO2 CT V  8.6O2 SAT V  61.4 Jul-31-2022 1230 Serology COVID  PosINFLUA  NegINFLUB  NegCVD1TEST  NoCVDEMPHC  YesCVDSYMP  NoCVDSYMDT  NoCVDHOSP  NoCVDICU  NoCVDRESID  NoCVDPREG  Not Pregnant Jul-31-2022 1230 Hematology WBC  11.8RBC  5.85HGB  18.6HCT  53.8MCV  92.0MCH  31.8MCHC  34.6RDW  13.3RDWSD  45.0PLT  293MPV  12.5AUTONEU%  82.1AUTOLYM%  7.0AUTOMON%  7.3AUTOEOS%  0.0AUTOBAS%  0.6AUTONEU#  9.7AUTOLYM#  0.8AUTOMON#  0.9AUTOBAS#  0.1AUTOEOS#  0.0NRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.36IG%  3.0 Jul-31-2022 1230 Chemistry GLUCOSE  818BUN  23CREAT  1.4MDRD GFR  39NA  130K  4.1CL  95CALCIUM  10.2ALK PHOS  147CO2  9.0AST  14ALT  17AST/ALT  0.8TL PROT  7.6ALBUMIN  4.2TBILI  0.7OSMO  304.5ANION GP  30.1BUN/CRE  16.4ALCOHOL  0HGBA1C  >13.5MEAN GLU  >403MAGNESIU  2.6TROPI-HS  14 Jul-31-2022 1205 Urinalysis Department SPECGRAV  1.020U-PH  6.0LEUCOCYT  NegativeNITRITES  NegativePROTEIN  30GLUCOSE  >=1000KETONES  >=80UROBILIN  0.2BILRUBIN  NegativeBLOOD  ModerateCOLOR  Lt. YellowCLARITY  ClearMICROSCP  YCULTURE  YWBC  NoneRBC  0-2SQUAM EP  3-5BACTERIA  NoneMUCUS  1+OTHER  Rare Budding Ye Jul-31-2022 1205 Microbiology C UR  Less than 1000 cfu/ml after two nights incubation Jul-31-2022 1205 Chemistry AMPHET  NegBARBIT  NegBENZO  NegCOCAINE  NegMETHADON  NegOPIATES  NegPCP  NegTHC  Neg Jul-26-2022 1750 Reference Lab $A1GLOB  0.3$A2GLOB  0.7$ABPR2  Dnr$ABPR3  Dnr$ABPROB  DnrALBUMIN  4.2$ALPHGAL  <0.10$ANASC  Negative$B2GLOB  0.4$BGLOB  0.5$COMPTL  >60$GGLOB  0.6$IGE  172$IGEIGG  12$INTERP2  See NotePROT TL  6.7$TRYPTSE  4.6 Jul-26-2022 1750 Hematology WBC  8.8RBC  6.02HGB  19.3HCT  54.1MCV  89.9MCH  32.1MCHC  35.7RDW  12.9RDWSD  42.1PLT  205MPV  13.6AUTONEU%  89.2AUTOLYM%  8.9AUTOMON%  0.9AUTOEOS%  0.0AUTOBAS%  0.2AUTONEU#  7.8AUTOLYM#  0.8AUTOMON#  0.1AUTOBAS#  0.0AUTOEOS#  0.0NRBC%  0.0NRBC  0.0ESR  1HGB/HCT  2.8IG#  0.07IG%  0.8 Jul-26-2022 1750 Chemistry TSH  1.15CRP  3.00FT4  1.24 Imaging Results IMAGING REPORT Lab Date of Exam: 7/31/2022 Gender: F DO Exam Description: CT HEAD/BRAIN WO DATE OF EXAM Jul 31, 2022 1:15:07 PM CDT PROCEDURES CT - Head WO HISTORY Altered Mental Status IV CONTRAST (if appl) Without CT Head Without Contrast: Comparison: None. Findings: Cortical Sulci are symmetric. Basal ganglia are unremarkable Mass effect: No shift in midline structures Intracranial bleeding: No intraparenchymal bleeding or abnormal extra axial blood fluid collections Pituitary: Normal in size Visualized sinuses: Clear Orbital structures: Unremarkable Calvarium: No depressed fractures. Impression: Unremarkable CT of the head Electronically signed on Jul 31, 2022 2:06:30 PM CDT by: MD Report Completed: Jul 31, 2022 2:06:30 PM CDT The above study was officially reviewed, dictated, and signed by a radiologist. Page 1 of 2 It has then been proxy signed by an associated at Facility. The below radiology associate assignment and electronic signature (proxy signature) only represents completion of the electronic process. Facility image(s) for this exam were not evaluated by any radiologist at Facility. The signature does not represent a review or interpretation of any radiology image(s) that were dictated in the report by the radiologist from Radiology. DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY:  MD DICTATED DATE AND TIME: 7/31/2022 2:09 PM CDT    ---------------------------------------------  IMAGING REPORT Facility Date of Exam: 7/31/2022 Gender: F Ordering Physician: DO Exam Description: CH-CHEST 1V DR DATE OF EXAM Jul 31, 2022 1:35:25 PM CDT PROCEDURES CR - Chest 1 view HISTORY Altered Mental Status IV CONTRAST (if appl) 1 view chest x-ray. Comparison: 06/07/2021, not available for comparison Findings: No consolidation or effusion. Heart size normal. No acute fracture. Impression: 1. Normal heart and lungs 2. There is a 10 cm hiatal hernia Electronically signed on Jul 31, 2022 2:01:50 PM CDT by: MD Report Completed: Jul 31, 2022 2:01:50 PM CDT The above study was officially reviewed, dictated, and signed by a radiologist from (teleradiology company). It has then been proxy signed by an associated at Facility. The below radiology associate assignment and electronic signature (proxy signature) only represents completion of the electronic process. This image(s) for this exam were not evaluated by any radiologist at Facility. The signature does not represent a review or interpretation of any radiology image(s) that were dictated in the report by the Page 1 of 2 radiologist from Radiology. DICTATED, TRANSCRIBED, AND ELECTRONICALLY SIGNED BY: MD DICTATED DATE AND TIME: 7/31/2022 2:09 PM CDT  Functional Status* No Functional Impairments  Mental Status* Normal Cognition  Social History tobacco use Never Smoked, Smoking Cessation No non smoker  alcohol use Wine, Current, 1 Drink Per Month  drug use No Known Use  marital status Widowed  sexual behavior not currently sexually active  occupation Receptionist at Medical Facility  Health Concerns Hyperglycemia  Wine, Current, 1 Drink Per Month  Father Deceased Malignant neoplastic disease  Mother Deceased Mass lesion of brain @ 16  Tobacco Cessation* Non-Smoker, Non Tobacco product user  Vital Signs Aug-04-2022 0200 T 98.1 HR 79 RR 18 BP   107 / 69 O2Sat 97 Aug-03-2022 2200 T 98.2 HR 81 RR 16 BP   105 / 66 O2Sat 98 PHYSICAL EXAM CONSTITUTIONAL: Patient is a healthy appearing 58-year-old female sitting in her hospital chair. She is non-diaphoretic and in no acute distress.  EYES: She is wearing glasses. Pupils are equally round and reactive to light bilaterally. No scleral icterus or conjunctival injection noted. No discharge noted. No jaundice.  CARDIOVASCULAR: Heart rate and rhythm with occasional gallop. There are no appreciable murmurs on auscultation. No peripheral edema. Radial and dorsal pedis pulses 2+ bilaterally.  RESPIRATORY: Patient is breathing on ambient air with no increased work of breathing. Breath sounds are present and equal in bilateral anterior lung fields with no crackles, rattles, or wheezing. No accessory muscle use.  GASTROINTESTINAL: Abdomen is soft and non-distended. There is no tenderness to light or deep palpation. Sounds present and normoactive.  GENITOURINARY: No foley catheter in place.  PSYCHIATRIC: Patient's mentation now approaching baseline. She is able to respond intelligently and appropriately to my questions. Mood and affect are appropriate and she seems pleasant this morning.  Hospital Course Patients is a 58 yo female who presented to the emergency department on 7/31/22 after she was pulled over by law enforcement for erratic driving. She was found to be hyperglycemic with ketouria suggestive of DKA. She was initiated on insulin drip and electrolyte regimen and over several days her anion gap acidosis improved. Patient was found to be COVID+ on admission, but was not symptomatic from her COVID. She had been vaccinated with Moderna previous to admission. She was found to have a pancreatitis on admission, which may have exacerbated her ketotic state. Renal injury present on admission improved during her stay. A metabolic encephalopathy improved during her visit as her acidosis improved. Phosphorus and Potassium were replaced repeatedly during her stay, and will be rechecked on Monday 8/9/22. Patient was transitioned to long acting insulin and mealtime carb count. Patient demonstrated capacity to administer these medications and was deemed stable to discharge with close follow up.  Condition at Discharge Stable  Discharge Medications Diabetic Supplies 1 EA MISCELLANEOUS CONTINUOUS INFUSION (Printed by SAMUELSON OLAF RESIDENT on Aug-04-2022 1021) HumaLOG KwikPen Subcutaneous Solution Pen-injector 100 UNIT/ML 3 UNT SUBCUTANEOUSLY 3 TIMES A DAY WITH MEALS (ePrescribed by RESIDENT on Aug-04-2022 1027) Either this or Lispro will be dispensed Insulin Glargine Solostar Subcutaneous Solution Pen-injector 100 UNIT/ML 30 UNT SUBCUTANEOUSLY ONCE A DAY (ePrescribed by RESIDENT on Aug-04-2022 1021) Insulin Lispro (1 Unit Dial) Subcutaneous Solution Pen-injector 100 UNIT/ML 3 UNT SUBCUTANEOUSLY 3 TIMES A DAY WITH MEALS (ePrescribed by RESIDENT on Aug-04-2022 1021) Either this or humalog will be dispensed Singulair Oral Tablet 10 MG 10 MG ORALLY ONCE A DAY Discharge Disposition Discharge to home  Plan Plan: -Diabetic Ketoacidosis, Blood glucose of 818 on admission, newly diagnosed Diabetes with hgbA1C of >13.5 on admission -Anion gap metabolic acidosis and Non-anion gap metabolic, resolved -Metabolic encephalopathy, resolved -Acute pancreatitis on admission, resolved -COVID positive without respiratory failure -Acute Kidney Injury, mild Cr elevation of 1.4 on admission, unknown baseline, resolved. -Acute hypokalemia -Pseudo-hyponatremia, corrected sodium 141 on admission, stable -Hypochloremia, 95 on admission, resolved -Hypermagnesemia, Mg 2.6 admission, resolved -Acute hypophosphatemia, secondary to insulin drip vs other etiology -Sinus Tachycardia, improved -Hiatal Hernia found incidentally on Chest XRAY 7/31 -Recent Allergic Reaction with Severe Urticaria rash on Upper extremities and trunk -Moderate aortic stenosis, echo 06/08/2021 -Cardiomegaly with moderate left ventricular hypertrophy -Grade 2 diastolic dysfunction echo 06/08/2021   Plan: Patient has been deemed stable and will discharge home today with close follow up.  Patient will have a blood draw in 1 week and BMP with results sent to Dr. for potassium trending.  Patient has demonstrated competency with insulin management and will be discharged with 30 units Glargine daily and a carb count Lispro or humalog (per , both in pen injectors. She will be prescribed lancets, needles, test strips and a glucose monitor.  Patient has been scheduled for a hospital follow up on Aug 9th at 2:30 pm with Dr.  A referral will be sent to endocrine for further diabetic workup with autoantibodies and diabetic management.  Plan of care discussed with Dr. and the patient. All are in agreement.  Primary Care Provider DO  Electronically signed by RESIDENT on Aug-04-2022 1528 I have seen and physically examined the patient on 8/4/22 and agree with the documentation of Dr. I have also discussed my findings and plan of care with Dr. Any changes and additional information are listed below.  Face to face evaluation performed on day of discharge. Patient discharged home on basal bolus insulin regimen. Patient has been educated on DM management and comfortable performed glucose checks/insulin injections. Patient to keep glucose logs for further insulin titration. F/u PCP/endocrinologist  Discharge time, greater than 30 minutes Electronically signed by DO on Aug-04-2022 1718