Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 05, 2023 20:35 EST   Verified By: MD on November 05, 2023 20:35 EST   Encounter Info: Hospital, Inpatient, 11/05/23 -     * Final Report *        Chief Complaint   Abdomen pain  History of Present Illness/Subjective     36-year-old female with past medical history COPD here with diffuse abdomen painx3 days of mild of moderate severity, radiating to the back, no relieving or exacerbating factors.  Reports fever to 101.  Also complaining of generalized weakness and malaise. Denies nausea, vomiting, abdomen pain.No shortness of air or diaphoresis.   Does report a mild cough productive of scant amounts of white sputum with some pleuritic chest pain.   White blood cell count 14,000, increased absolute neutrophil count.Mildly elevated D-dimer.  Potassium 2.8, alkaline phosphatase 164, minimal elevation of AST and ALT, total bilirubin is normal, she has prior cholecystectomy.  Serum lactate is 0.7, cardiac enzymes are negative.  Urine shows bacteria, pyuria ,microhematuria, nitrite positivity.   COVID-19 positive as well.  Normotensive with mean arterial pressure in the 70s but systolic blood pressure on the soft side in the high 90s and low 100s. Mildly tachycardic.No hypoxia.   CT of the abdomen pelvis shows decreased cortical perfusion in a patchy distribution as well as perinephric stranding bilaterally.  CT angiography shows no acute abnormality including pulmonary embolus.  Review of Systems     Complains of mild nonproductive cough, pleuritic chest pain, fever,abdomen pain.  Denies shortness of air.  No nausea vomiting or diarrhea hematochezia or melena.  Remaining 10 point review of systems negative except as noted above.  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 37.5 °C (Oral)  BP: 98/65  HR: 112 (Monitored)  HR: 110 (Peripheral)  RR: 17  SpO2: 96%  Oxygen Therapy: Room air  WT: 50.30 kg (WFC)   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    50.3 kg    11/05/23    Patient Height  Current Height:    162.6 cm    11/05/23        Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA,  EOMI, normal conjunctiva ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, non-distended Musculoskeletal:  No joint swelling, no deformity, bilateral CVA tenderness to palpation 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. Acute pyelonephritis   N10   The patient has no multidrug-resistant risk factors thus will prescribe  ceftriaxone 1 g every 24 hours, pain control, as needed antiemetics, follow cultures, follow procalcitonin levels.   2. COVID-19 virus infection   U07.1   Not sure we can call this asymptomatic with fever, however, no hypoxia.  Supportive care.   3. Sepsis   A41.9   Present on admission secondary to urinary tract infection.  Follow bolus guidelines and then administer maintenance IV fluids to maintain a mean arterial pressure of 65 and urine output of 50 mL/h.  Recheck on physical examination shows appropriate capillary refill and peripheral tissue perfusion.  We will follow urine and blood cultures.  Antibiotics as described above.  This is a urinary tract infection in a young female with nitrite positivity, no indication for gram-positive coverage at this point.   4. Elevated liver enzymes   R74.8   Chronic, stable, follow   5. Hypokalemia   E87.6   Replete and follow   Orders:   albuterol, 2 Puff, Inhalation, MDI/DPI Inhaler Treatment, 4 Times Daily, 11/05/23 21:00:00 EST  Sodium Chloride 0.9% 500 mL, Total Volume (mL) = 500, IV Continuous, 11/05/23 19:50:00 EST, Other - See Comments, Clinical Weight  Sodium Chloride 0.9% 500 mL, Total Volume (mL) = 500, IV Continuous, 11/05/23 19:50:00 EST, Other - See Comments, Clinical Weight  Full code   Lovenox  Code Status   Full Code   Chronic Problem List    Extensive tattoos  History of conization of cervix  History of depression  History of migraine headaches  Request for sterilization  Procedure/Surgical History  ?Laparoscopic cholecystectomy (01/11/2023) ?Oral surgery (02/2016) ?Pap smear for cervical cancer screening.... (06/16/2015) ?Colposcopy (06/09/2006) ?Abnormal pap smear (03/07/2006) ?Extraction of wisdom tooth (2003) ?Conization of uterine cervix (12/18/2001) ?cholesystectomy   Surgical History Internal  01/11/2023    Cholecystectomy Laparoscopic    MD  08/14/2020    Tubal Ligation Laparoscopic    MD  Medications   Home Medications (3) Active  Benadryl 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, At Bedtime  Ventolin HFA 90 mCg/inh inhalation aerosol 180 mCg = 2 Puff, Inhalation, 4 Times Daily, May use up to 3-4 puffs four times a day.  Wixela Inhub 500 mCg-50 mCg inhalation powder , Inhalation, BID  Active Scheduled Inpatient Medications  albuterol (Albuterol (Eqv-Ventolin HFA) 90 mCg/inh inhalation aerosol), Aerosol, 2 Puff, Inhalation, 4 Times Daily, Start: 11/05/23 21:00:00  potassium chloride (potassium chloride extended release), Tab, Extended Rel, 20 mEq, Orally, ONCE, Start: 11/05/23 17:00:00  Sodium Chloride 0.9%  500 mL IV Continuous  Other - See Comments     Sodium Chloride 0.9%  500 mL IV Continuous  Other - See Comments       One-Time Medications Given 11/04/23 00:00:00 TO 11/05/23 20:34:49  ceftRIAXone, Injection, 1 GM, IV Push, ONCE, (1 DOSE 11/05/23 16:02:00)  HYDROmorphone (HYDROmorphone Inj ED (1 mg/mL)), Injection, 1 mg, IV Push, ONCE, (1 DOSE 11/05/23 15:06:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, prn, Nausea/Vomiting IV - Use First, (1 DOSE 11/05/23 15:06:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 500 mL, IVPB, ONCE, (1 DOSE 11/05/23 15:04:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 11/05/23 18:09:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 11/05/23 18:09:00)  PRN Medications (0600 - 0559) from 11/04 - 11/05  HYDROmorphone, 1 mg, IV Push, Q10min, 0  Dose(s)   Allergies   morphine (Itching, Hives)  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Employed, Work/School description: GM x 10 years. Highest education level: Some college.   Home/Environment   (Married, has been together since 2013), Lives with Children, Spouse.   Nutrition/Health   Diet: Regular.   Other   Sexual   Sexually active: Yes. History of sexual abuse: Yes. Other sexual concerns: Pt states she was sexually abused at age 10 by brother's friend. She states her first husband was physically abusive. ACE Score-5 Declines any counseling at present. States she had counseling in the past..   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Alcoholism /alcohol abuse...: Mother and Father.  Anxiety: Mother.  Blood clot: Aunt.  Breast cancer: Grandmother (M).  COPD (chronic obstructive pulmonary disease)...: Mother.  DVT (deep venous thrombosis)....: Aunt.  Depression: Mother.  Drug abuse: Father and Brother.  Drug dependency...: Brother.  Hepatitis c, chronic...: Father.  Hypertension: Mother.  Hypertension..: Father.  Lung cancer..: Grandfather (P).  Migraines..: Mother.  Miscarriage: Mother.  Myocardial infarction...: Grandfather (M).  Rheumatoid arthritis: Mother.  Skin cancer: Grandfather (M).  Grandmother (P): History is negative  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 14.4 k/cumm High (11/05/23 14:51:00)  RBC: 3.4 million/cumm Low (11/05/23 14:51:00)  Hgb: 10.1 GM/dL Low (11/05/23 14:51:00)  Hct: 29.7 % Low (11/05/23 14:51:00)  MCV: 88 fL (11/05/23 14:51:00)  MCH: 29.6 pg (11/05/23 14:51:00)  MCHC: 33.9 GM/dL (11/05/23 14:51:00)  RDW: 13.7 % (11/05/23 14:51:00)  Platelet: 238 k/cumm (11/05/23 14:51:00)  MPV: 8 fL (11/05/23 14:51:00)  Neutrophils %: 84 % (11/05/23 14:51:00)  Lymphocytes %: 4 % (11/05/23 14:51:00)  Monocytes %: 12 % (11/05/23 14:51:00)  Eosinophils %: 0 % (11/05/23 14:51:00)  Basophils %: 0 % (11/05/23 14:51:00)  Absolute Neutrophil: 12.1 k/cumm High (11/05/23 14:51:00)  Absolute Lymphocyte: 0.5 k/cumm Low (11/05/23 14:51:00)  Absolute Monocyte: 1.8 k/cumm High (11/05/23 14:51:00)  Absolute Eosinophil: 0 k/cumm (11/05/23 14:51:00)  Absolute Basophil: 0 k/cumm (11/05/23 14:51:00)  Chemistry:  Sodium SerPl QN: 138 mmol/L (11/05/23 14:51:00)  Potassium SerPl QN: 2.8 mmol/L Critical (11/05/23 14:51:00)  Chloride SerPl QN: 103 mmol/L (11/05/23 14:51:00)  Carbon Dioxide SerPl QN: 24 mmol/L (11/05/23 14:51:00)  Anion Gap: 11 mmol/L (11/05/23 14:51:00)  BUN SerPl QN: 12 mg/dL (11/05/23 14:51:00)  Creatinine SerPl QN: 0.84 mg/dL (11/05/23 14:51:00)  Estimated GFR (CKD-EPI, no race): >90 (11/05/23 14:51:00)  Estimated CRCL (CG): 74 mL/min (11/05/23 14:51:00)  Glucose SerPl QN: 93 mg/dL (11/05/23 14:51:00)  Calcium Total SerPl QN: 8.2 mg/dL Low (11/05/23 14:51:00)  Alkaline Phos SerPl QN: 164 Units/L High (11/05/23 14:51:00)  ALT SerPl QN: 75 Units/L High (11/05/23 14:51:00)  AST SerPl QN: 53 Units/L High (11/05/23 14:51:00)  Bilirubin Total SerPl QN: 1 mg/dL (11/05/23 14:51:00)  Total Protein SerPl QN: 6.4 GM/dL (11/05/23 14:51:00)  Albumin SerPl QN: 3.4 GM/dL Low (11/05/23 14:51:00)  Lipase SerPl QN: 12 Units/L (11/05/23 14:51:00)  Troponin-I High Sensitivity: 7 ng/L (11/05/23 15:57:00)  Lactate Venous Pl QN: 0.7 mmol/L (11/05/23 14:51:00)  Coagulation:  D-Dimer Pl QN: 304 ng/mL DDU High (11/05/23 14:51:00)  Urine Studies:  Pregnancy Test Urine: Negative (11/05/23 14:34:00)  Color: Yellow (11/05/23 14:34:00)  Clarity: Slightly Cloudy (11/05/23 14:34:00)  Specific Gravity: 1.022 (11/05/23 14:34:00)  pH: 6 (11/05/23 14:34:00)  Protein: 100 Abnormal (11/05/23 14:34:00)  Glucose: Normal (11/05/23 14:34:00)  Ketones: 20 Abnormal (11/05/23 14:34:00)  Bilirubin: NEGATIVE (11/05/23 14:34:00)  Hgb Ur: TRACE. Abnormal (11/05/23 14:34:00)  Nitrite: Positive 2+ Abnormal (11/05/23 14:34:00)  Urobilinogen: 2.0 2 Abnormal (11/05/23 14:34:00)  Leukocyte Esterase Ur: Large500 Abnormal (11/05/23 14:34:00)  WBC: >100 Abnormal (11/05/23 14:34:00)  RBC: 11-20 Abnormal (11/05/23 14:34:00)  Bacteria: Many Abnormal (11/05/23 14:34:00)  Squamous Epithelial: Few (11/05/23 14:34:00)  Mucous: PRESENT. (11/05/23 14:34:00)  Hyaline Casts: 3-5 (11/05/23 14:34:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (11/05/23 14:34:00)  Coronavirus SARS-CoV2 Rapid: Detected Abnormal (11/05/23 14:34:00)  Micro - Last 7 days  Rapid Influenza Method: PCR - Liat (11/05/23 14:34:00)  Rapid Influenza A PCR: Not Detected (11/05/23 14:34:00)  Rapid Influenza B PCR: Not Detected (11/05/23 14:34:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 11/05/2023 16:55 - CTA Abd/Pelvis WO/W IV Contrast  IMPRESSION:1.  Negative for aortic dissection.2.  Findings most consistent with RIGHT worse than LEFTpyelonephritis. No evidence of ureteral obstruction.3.  Small volume free fluid in the pelvis may be physiologic in areproductive age female.4.  Borderline splenomegaly.Thank you for consulting our team of subspecialty radiologists at Physicians Radiology.      11/05/2023 16:55 - CTA Chest WO/W IV Contrast  IMPRESSION:1.  No acute findings in the chest. Abdominopelvic findings reportedseparately.Thank you for consulting our team of subspecialty radiologists at Physicians Radiology.                  Signature Line Electronically Signed on 11/05/23 20:35 EST ________________________________________________________ MD