Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: NP on October 31, 2023 14:12    Verified By: NP on October 31, 2023 14:45   Encounter Info: Hospital, Inpatient, 10/31/23 -     * Final Report *  Document Contains Addenda          History of Present Illness/Subjective     This is a 39 year old patient with a past medical history significant for Asthma that presented to Ed on 10/31/2023 from home via POV with c/o a breast wound and is being admitted to inpatient for breast abscess and outpatient treatment failure.   This patient was seen and evaluated while still in the ED.  She was found to be lying in bed, alert and oriented and in no distress.  C/o breast abscess for 1.5 weeks.  She was seen in the facility on 10/27/23 and given a Rocephin and a prescription for Bactrim DS. She continues on her Bactrim but in the meantime she has developed fever, chills, nausea, and the abscess has worsened. 3 months postpartum, weaned her infant approx 1 month ago, denies engorgement and feels she is no longer lactating.    Afebrile. All other vs stable and wnl. CMP and CBC nonactionable.    Review of Systems     Constitutional:  No fevers,  no chills,  no sweats Eyes:  No changes in vision Ears, Nose, Mouth, Throat:  No ear pain,  no nasal congestion,  no sore throat Respiratory:  No shortness of breath,  no cough,  no wheeze Cardiovascular:  No chest pain,  no palpitations,  no edema Gastrointestinal:  No abdominal pain,  no nausea,  no vomiting,  no diarrhea,  no constipation Genitourinary:  No frequency,  no urgency,  no dysuria,  no hematuria Hematologic/Lymphatic:  No bruising,  no enlarged lymph nodes Allergic/Immunologic:  No hives Endocrine:  No cold intolerance,  no heat intolerance,  no polyuria,  no polydipsia Musculoskeletal:  No arthralgia,  no myalgia Skin: +erythema and blackened area Neurological:  No headache,  no focal weakness,  no numbness Psychiatric:  No anxiety,  no depression  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 36.8 °C (Oral)  BP: 112/73  HR: 80 (Monitored)  RR: 16  SpO2: 98%  Oxygen Therapy: Room air  WT: 76.80 kg (WFC)   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    76.8 kg    10/31/23    Patient Height  Current Height:    152 cm    10/31/23        Constitutional:  No acute distress,  well-nourished Eyes:  PERRLA,  EOMI,  normal conjunctiva,  no scleral icterus 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, intact ROM Integumentary:  see clinical media Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan     This is a 39 year old patient with a past medical history significant for Asthma that presented to Ed on 10/31/2023 from home via POV with c/o a breast wound and is being admitted to inpatient for breast abscess and outpatient treatment failure. This is a 39 year old patient with a past medical history significant for Asthma that presented to Ed on 10/31/2023 from home via POV with c/o a breast wound and is being admitted to inpatient for breast abscess and outpatient treatment failure.    1. Breast abscess   N61.1  failed outpatient treatment   does not meet sepsis criteria   IV atbx, blood cx pending  surgery following for possible I/D  will have oncology consult to r/o breast ca   2. Failure of outpatient treatment   Z78.9  treated with one dose of Ceftx and a bactrim script.  no improvement   see plan above    3. Mastitis   N61.0   see plan above   4. Anxiety and depression   F41.9   continue lexapro    5. Hashimoto's thyroiditis   E06.3   continue levothyroxine    6. Narcolepsy   G47.419   noted.    7. Asthma   J45.909   not in exacerbation    Inpt, medical floor  Daily labs - CBC, CMP Daily   Regular Diet  IV fluids SL   Full Code Status  VTE Prophylaxis - Heparin      Code Status   None Recorded   Chronic Problem List    Abscess of breast  Adenoma of colon  Advanced maternal age in multigravida  Anxiety and depression  Attention deficit hyperactivity disorder  Colon polyp  Family history of colon cancer in mother  Family history of hemophilia  Family history of secondary malignant neoplasm of large intestine and rectum  Hair loss  Hashimoto's thyroiditis  Irritable bowel syndrome with diarrhea  Kidney stones  Major depression, recurrent, chronic  Migraines  Narcolepsy  Obesity, Class I, BMI 30-34.9  Panic disorder without agoraphobia  Positive screening for depression on 2-item Patient Health Questionnaire (PHQ-2)  Seasonal allergies  Procedure/Surgical History  ?Cystoscopy, Right Ureteroscopy , Laser Lithotripsy, Right Stent placement (08/11/2021) ?Cystoscopy, insert reteral Stent (07/21/2021) ?Kidney stone (07/21/2021) ?Date of last PAP smear (07/06/2021) ?Colonoscopy (01/06/2021) ?cesarean section (08/16/2015) ?Nasal bones, closed fracture.. (2003) ?Wisdom Teeth Removed (2003)   Surgical History Internal  08/01/2023    Cesarean Section.    MD  08/11/2021    Ureteroscopy.  (Right)   MD  07/21/2021    Cystoscopy Insert Ureteral Stent or Cath  (Right)   MD  01/06/2021    Colonscpy Snare Tmr Polyp Lsn   MD PhD  08/06/2015    Cesarean Section.    MD  Medications   Home Medications (6) Active  acetaminophen 500 mg oral tablet 1,000 mg = 2 Tablet, Orally, Q8H  amphetamine-dextroamphetamine 10 mg tablet 20 mg  Bactrim DS 800 mg-160 mg oral tablet 1 Tablet, Orally, BID  escitalopram 20 mg oral tablet 20 mg = 1 Tablet, Orally, Daily  levothyroxine 137 mCg (0.137 mg) oral tablet 137 mCg = 1 Tablet, Orally, Daily, Avoid antacids, calcium, or iron for at least 4 hrs before or 4 hrs afterAs a single daily dose before breakfast  Sunosi 150 mg oral tablet   Active Scheduled Inpatient Medications  piperacillin-tazobactam, Injection, 3.375 GM, IVPB, ONCE, Indication: SSTI - Severe/DFI/Necrotizing Fasciitis, Start: 10/31/23 17:00:00    One-Time Medications Given 10/30/23 00:00:00 TO 10/31/23 14:12:32  ketoROLAC, Injection, 15 mg, IV Push, ONCE, (1 DOSE 10/31/23 12:52:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 10/31/23 12:52:00)  piperacillin-tazobactam, Injection, 4.5 GM, IV Push, ONCE, (1 DOSE 10/31/23 12:52:00)  vancomycin, Injection, 1.5 GM, IVPB, ONCE, (1 DOSE 10/31/23 13:12:00)  PRN Medications (0600 - 0559) from 10/30 - 10/31  None Reported  Allergies   Ambien (Hallucinations)  HYDROcodone (Itching)  Latex (mild itching)  Social History    Alcohol   Current, 1-2 times per month   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Employed, Work/School description: LPN-Select Home Health. Highest education level: Some college.   Exercise   Exercise frequency: Does Not Exercise.   Home/Environment   FOB: - Relationship since 9/2022, Lives with Significant other, and her daughter.   Nutrition/Health   Diet: Regular. Caffeine intake amount: <200mg daily.   Other   ACE: 4 Pt declined HFI   Psychosocial   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Alcohol abuse: Father.  Asthma: Brother.  Cancer of colon: Mother.  Depression: Mother, Father, Sister and Brother.  Hypertension: Mother, Grandfather (P) and Grandmother (M).  Thyroid disorder: Aunt, Grandmother (P), Maternal Cousin and Paternal Cousin.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.8 k/cumm High (10/31/23 12:40:00)  RBC: 4.39 million/cumm (10/31/23 12:40:00)  Hgb: 13.3 GM/dL (10/31/23 12:40:00)  Hct: 39.2 % (10/31/23 12:40:00)  MCV: 89 fL (10/31/23 12:40:00)  MCH: 30.3 pg (10/31/23 12:40:00)  MCHC: 33.9 GM/dL (10/31/23 12:40:00)  RDW: 13.7 % (10/31/23 12:40:00)  Platelet: 350 k/cumm (10/31/23 12:40:00)  MPV: 7.8 fL (10/31/23 12:40:00)  Neutrophils %: 74 % (10/31/23 12:40:00)  Lymphocytes %: 17 % (10/31/23 12:40:00)  Monocytes %: 5 % (10/31/23 12:40:00)  Eosinophils %: 3 % (10/31/23 12:40:00)  Basophils %: 0 % (10/31/23 12:40:00)  Absolute Neutrophil: 8.1 k/cumm High (10/31/23 12:40:00)  Absolute Lymphocyte: 1.9 k/cumm (10/31/23 12:40:00)  Absolute Monocyte: 0.5 k/cumm (10/31/23 12:40:00)  Absolute Eosinophil: 0.3 k/cumm (10/31/23 12:40:00)  Absolute Basophil: 0 k/cumm (10/31/23 12:40:00)  Chemistry:  Sodium SerPl QN: 139 mmol/L (10/31/23 12:40:00)  Potassium SerPl QN: 3.5 mmol/L (10/31/23 12:40:00)  Chloride SerPl QN: 105 mmol/L (10/31/23 12:40:00)  Carbon Dioxide SerPl QN: 27 mmol/L (10/31/23 12:40:00)  Anion Gap: 7 mmol/L (10/31/23 12:40:00)  BUN SerPl QN: 7 mg/dL (10/31/23 12:40:00)  Creatinine SerPl QN: 0.92 mg/dL (10/31/23 12:40:00)  Estimated GFR (CKD-EPI, no race): 81 mL/min/1.73m2 (10/31/23 12:40:00)  Estimated CRCL (CG): 75 mL/min (10/31/23 12:40:00)  Glucose SerPl QN: 86 mg/dL (10/31/23 12:40:00)  Calcium Total SerPl QN: 9.3 mg/dL (10/31/23 12:40:00)  Lactate Venous Pl QN: 1.1 mmol/L (10/31/23 12:40:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.             Signature Line Electronically Signed on 10/31/23 14:45 ________________________________________________________ NP     Addendum by MD on October 31, 2023 18:52:21 (Verified)    I saw and evaluated the patient in addition to NP.  I provided a substantive portion of the care for this patient. I have reviewed and verified this documentation and it accurately reflects our care.   39-year-old woman admitted to the hospital for left breast redness and pain of 1 week duration.  Patient notes that left breast pain and redness started small but has gradually worsened.  She reports a high-grade fever at home.  Recent history of breast-feeding but last breast-fed 1 month ago.  No history of prior breast abscess or engorgement.  No recent history of mammogram or breast ultrasound.  Currently complains of poor pain control.  Vital signs are stable.  We will continue current antibiotics.  Surgery eval to follow.  General: Alert and oriented, No acute distress. Eye: Normal conjunctiva. Cardiovascular: Regular rate, Normal rhythm, No murmur. Respiratory: Lungs are clear to auscultation, Respirations are non-labored. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly. Neurologic: no focal deficits Psychiatric: Cooperative, Appropriate mood & affect. Musculoskeletal: No swelling,  Breast exam-necrotic appearing mass on the left outer quadrant of the left breast, with surrounding redness and peau d'orange appearance, very tender to palpation   I spent more than 30 minutes in the entire evaluation  MD   Signature Line Electronically Signed on 10/31/23 18:55  ________________________________________________________ MD