Physician  Specialty:  Emergency Medicine     ED Provider Notes     Signed     Date of Service:  07/30/22 0738                        Expand widget buttonCollapse widget button     Hide copied text   Hover for detailscustomization button                                                                                                                                          (F) - 37 y.o.  Note Creation:7/30/2022  Encounter Date:7/30/2022        History           Chief Complaint    Patient presents with    ?   Fatigue          Patient is a 37 y.o. female with hx of anemia, renal disease, and obesity who presents to the ED via PV with husband at bedside as a transfer with c/o worsening headache that began a few days PTA. Pt states she has been having headaches, elevated heart rate, fever, weakness, lower back pain, and an appetite change over the past few days. Pt was seen at outside hospital for her symptoms and was told she had COVID PNA. Pt was transferred to this facility for further evaluation and care of her symptoms. Pt states she is  A dialysis patient and is compliant to home hemodialysis. Pt states she follows with Nephrologist. Pt states she is vaccinated x 2 but doesn't have the booster. She denies chest pain, abd pain, cough, chills, or any other pertinent symptoms or concerns. She denies any other aggravating or alleviating factors. She denies any other pertinent PMHx.     The history is provided by medical records and the patient.              Past Medical History:    Diagnosis   Date    ?   Acid reflux        ?   Anemia        ?   Anemia of chronic disease        ?   Anxiety        ?   Ascending aorta dilatation        ?   Asthma        ?   Blood transfusion without reported diagnosis        ?   Cigarette smoker            At least 1 PPD    ?   Community acquired pneumonia   last 6/09        several times    ?   Diabetes mellitus            RESOLVED PER WEIGHT LOSS    ?   Dialysis patient            4 times a week    ?   ESRD (end stage renal disease)        ?   Fibrillary glomerulonephritis        ?   FSGS (focal segmental glomerulosclerosis) with nephrosis        ?   Hemangioma NOS            mid forehead    ?   Hiatal hernia        ?   History of sleeve gastrectomy        ?   HX OTHER MEDICAL            LMP 8/15/09 (irregular periods)   G--0    ?   Hypertension        ?   Irritable bowel syndrome        ?   Juvenile rheumatoid arthritis            age 9 to 12 took medication then after age 12 did not test postive    ?   Melanoma   2002        Melanoma right chest area--surgery    ?   Obesity (BMI 30.0-34.9)        ?   SVT (supraventricular tachycardia)   03/22/2022        PBH    ?   Tobacco abuse        ?   UTI (urinary tract infection)                    Past Surgical History:    Procedure   Laterality   Date    ?   AV FISTULOGRAM   Left   3/20/2020        AV Fistulogram   ?   AV FISTULOGRAM   Left   11/26/2019        AV Fistulogram   ?   AV FISTULOGRAM   Left   7/9/2019        AV Fistulogram     ?   AV FISTULOGRAM   Left   3/1/2019        AV FISTULOGRAM     ?   AV FISTULOGRAM   Left   3/16/2021        AV Fistulogram     ?   AV FISTULOGRAM WITH DECLOT   Left   5/26/2020        AV FISTULOGRAM WITH DECLOT     ?   BONE MARROW BIOPSY   N/A   2/7/2022        Bone Marrow Biopsy     ?   CATHETER REMOVAL   N/A   4/2/2019        CATHETER REMOVAL     ?   HX ARTERIO-VENOUS GRAFT LIGATION   Left   3/1/2019        LEFT UPPER EXTREMITY, ARTERIO-VENOUS GRAFT     ?   HX BARIATRIC SURGERY            ?   HX CESAREAN SECTION            ?   HX CHOLECYSTECTOMY            ?   HX COLONOSCOPY       7/09        colonoscopy & upper endoscopy   ?   HX EGJ   N/A   12/2/2021        EGD /C BIOPSY     ?   HX EGJ       12/2/2021        EGD /C GOLD PROBE CAUTERY     ?   HX GASTRECTOMY, SLEEVE            ?   HX HYSTERECTOMY            ?   HX SKIN CANCER REMOVAL       2001-2003        3 seperate time (2 on right chest and 1 on right upper arm)---MD office    ?   PERIPHERAL INTERVENTION UPPER   Left   3/20/2020        Peripheral Intervention Upper     ?   PERIPHERAL INTERVENTION UPPER       11/26/2019        Peripheral Intervention Upper     ?   PERIPHERAL INTERVENTION UPPER       3/16/2021        Peripheral Intervention Upper     ?   PERIPHERAL STENT       3/16/2021        Peripheral Stent     ?   VENOUS PTA   N/A   5/26/2020        Venous PTA     ?   VENOUS PTA   Left   7/9/2019        Venous PTA                 Family History    Problem   Relation   Age of Onset    ?   Asthma   Mother        ?   Hypertension   Mother        ?   Heart Disease   Father        ?   Stroke   Father        ?   Heart Disease   Paternal Grandmother        ?   Heart Attack   Paternal Grandmother        ?   Coronary Artery Disease   Paternal Grandmother               Social History             Tobacco Use    ?   Smoking status:   Current Every Day Smoker            Packs/day:   1.00            Years:   17.00            Pack years:   17.00            Types:   Cigarettes    ?   Smokeless tobacco:   Never Used    Vaping Use    ?   Vaping Use:   Never used    Substance Use Topics    ?   Alcohol use:   Not Currently            Comment: once a year    ?   Drug use:   No          Patient is a tobacco user, and I have offered a counseling referral.     Patient's last menstrual period was 06/19/2013.          Allergies    Allergen   Reactions    ?   Ivp Dye [Iodine]   Hives and Itching    ?   Bystolic [Nebivolol]   Hives and Nausea And Vomiting    ?   Penicillins   Shortness Of Breath and Swelling    ?   Vancomycin   Hives and Itching               Current Outpatient Medications on File Prior to Encounter    Medication   Sig    ?   safety needles 28 gauge x 1/2" Ndle   1 Dose Every month.    ?   cyanocobalamin (VITAMIN B12) 1,000 mcg/mL injection   Administer 1 mL intramuscularly Every month for 30 days.    ?   tiZANidine (ZANAFLEX) 4 mg tablet   Take 4 mg by mouth Every 6 hours.    ?   Promethazine 12.5 mg tablet   Take 12.5 mg by mouth Four times a day.    ?   hydrOXYzine pamoate (VISTARIL) 25 mg capsule   Take 25 mg by mouth Four times a day.    ?   valsartan-hydrochlorothiazide (DIOVAN HCT) 320-12.5 mg tablet   Take 1 Tablet by mouth Once Daily.    ?   minoxidiL (LONITEN) 2.5 mg tablet   Take 5 mg by mouth Once Daily.    ?   famotidine (PEPCID AC) 20 mg tablet   Take 20 mg by mouth Twice a day.    ?   busPIRone (BUSPAR) 5 mg tablet   Take 5 mg by mouth Twice a day.    ?   ferric citrate (AURYXIA) 210 mg iron Tab   Take 420 mg by mouth Three times a day.    ?   albuterol (VENTOLIN HFA) 90 mcg/Actuation inhaler   Take 180 mcg by inhalation Every 4 hours.    ?   folic acid/vit B complex and C (RENAL-VITE PO)   Take  by mouth.    ?   clobetasoL (TEMOVATE) 0.05 % cream   Apply BID after plain water soaks, then Cetaphil or CeraVe cream to all skin.Do not use on face,breasts,underarms or groin.    ?   Benzonatate (TESSALON PERLES) 200 mg capsule   Take 1 Capsule by mouth Three times a day as needed for Cough.    ?   cloNIDine HCL (CATAPRES) 0.2 mg tablet   Take 1 Tablet by mouth Twice a day.    ?   Labetalol 300 mg tablet   Take 300 mg by mouth Three times a day.    ?   diltiazem (CARDIZEM CD) 120 mg XR capsule   Take 1 Capsule by mouth Once Daily.    ?   folic acid (FOLVITE) 1 mg tablet   Take 1 Tablet by mouth Daily.    ?   ergocalciferol (VITAMIN D2) 50,000 unit CAPSULE   Take 1 Capsule by mouth Every week.    ?   furosemide (LASIX) 80 mg tablet   Take 80 mg by mouth Daily.    ?   lanthanum (FOSRENOL) 500 mg   Take 1,500 mg by mouth Three times a day.    ?   epoetin beta, methoxy peg 100 mcg/0.3 mL Syrg   Administer 100 mcg by injection Every month. EVERY OTHER WEEK    ?   iron sucrose (VENOFER) 100 mg/5 mL   Administer 100 mg intravenously Every week.    ?   HEPARIN IV   Administer 5,000 Units intravenously Every week.    ?   aspirin (ASPIRIN) 81 mg DR tablet   Take 81 mg by mouth Daily.    ?   allopurinol (ZYLOPRIM) 300 mg tablet   Take 600 mg by mouth Twice a day.           Review of Systems       Review of Systems   Constitutional: Positive for appetite change, fatigue and fever. Negative for chills and diaphoresis.   HENT: Negative.  Negative for congestion.    Eyes: Negative.  Negative for visual disturbance.   Respiratory: Negative.  Negative for cough and shortness of breath.    Cardiovascular: Positive for palpitations. Negative for chest pain.   Gastrointestinal: Negative.  Negative for abdominal distention, diarrhea, nausea and vomiting.   Genitourinary: Negative.  Negative for dysuria and urgency.   Musculoskeletal: Positive for back pain (lower). Negative for arthralgias and myalgias.   Skin: Negative.  Negative for wound.   Neurological: Positive for weakness and headaches.   Psychiatric/Behavioral: Negative.  Negative for behavioral problems.   All other systems reviewed and are negative.         Physical Exam              ED Triage Vitals    BP   BP Manual or Automatic?   Patient Position   BP Location   Heart Rate (Monitor)    07/30/22 0643   07/30/22 0643   07/30/22 0643   07/30/22 0643   07/30/22 0643    155/84   Automatic   Sitting   Right Arm   87         Pulse   Pulse Source   Respirations   Temp   Temp Source    07/30/22 0645   07/30/22 1643   07/30/22 0700   07/30/22 0643   07/30/22 0643    86   Radial   12   99.8 °F (37.7 °C)   Oral         SpO2   SPO2 Location   O2 Delivery   O2 Device   O2 Flow Rate (l/min)    07/30/22 0643   --   07/30/22 0643   --   --    100 %       Room air                 FIO2 (%)   Pain Intensity 1   Exacerbated By   Relieved By   Quality    --   --   --   --   --                              Duration                    --                                               Physical Exam  Vitals and nursing note reviewed.  Constitutional:       Appearance: She is well-developed.  HENT:      Head: Atraumatic.     Mouth/Throat:     Mouth: Mucous membranes are moist.     Pharynx: No oropharyngeal exudate.  Eyes:      Conjunctiva/sclera: Conjunctivae normal.     Pupils: Pupils are equal, round, and reactive to light.  Neck:      Thyroid: No thyromegaly.  Cardiovascular:      Rate and Rhythm: Normal rate and regular rhythm.     Pulses: Normal pulses.     Heart sounds: Normal heart sounds. No murmur heard. Pulmonary:      Effort: Pulmonary effort is normal. No respiratory distress.     Breath sounds: Normal breath sounds. No stridor. No wheezing.  Abdominal:     General: Bowel sounds are normal. There is no distension.     Palpations: Abdomen is soft.     Tenderness: There is no abdominal tenderness. There is no rebound.   Musculoskeletal:         General: No tenderness. Normal range of motion.     Cervical back: Normal range of motion and neck supple.   Lymphadenopathy:      Cervical: No cervical adenopathy.  Skin:     Findings: No erythema or rash.  Neurological:      General: No focal deficit present.     Mental Status: She is alert and oriented to person, place, and time.     Cranial Nerves: No cranial nerve deficit.  Psychiatric:        Mood and Affect: Mood normal.             MDM       Treatment:  Procedures      Medications    labetaloL (NORMODYNE) tab 300 mg (300 mg Oral Not Given 7/30/22 1034)    valsartan (DIOVAN) 320 mg, hydroCHLOROthiazide (HYDRODIURIL) 12.5 mg ( Oral Not Given 7/30/22 1034)    busPIRone (BUSPAR) tab 5 mg (5 mg Oral Not Given 7/30/22 1034)    hydrOXYzine pamoate (VISTARIL) cap 25 mg (25 mg Oral Not Given 7/30/22 1034)    cloNIDine HCL (CATAPRES) tab 0.2 mg (0.2 mg Oral Not Given 7/30/22 1034)    minoxidiL (LONITEN) tab 5 mg (5 mg Oral Not Given 7/30/22 1034)    diltiazem (CARDIZEM CD) ER cap 120 mg (has no administration in time range)    famotidine (PEPCID) tab 20 mg (has no administration in time range)    insulin regular (novoLIN R) injection 10 Units (has no administration in time range)    calcium gluconate in NaCl (ISO-OS) 100ml (PREMIX) 2 g (has no administration in time range)    albuterol (PROVENTIL) neb soln 2.5 mg (has no administration in time range)    hePARin (porcine) injection 5,000 Units (5,000 Units Subcutaneous Not Given 7/30/22 1034)    zinc sulfate (ZINCATE) cap 220 mg (has no administration in time range)    ascorbic acid (vitamin C) tab 500 mg (500 mg Oral Not Given 7/30/22 1034)    melatonin tab 6 mg (has no administration in time range)    cholecalciferol (vitamin D3) (VITAMIN D3) tab 4,000 Units (has no administration in time range)    -PHARMACY TO DOSE REMDESIVIR- 1 Each (has no administration in time range)    insulin aspart U-100 (NovoLOG) injection (has no administration in time range)    NS (sodium chloride 0.9%) IV infusion (has no administration in time range)    albumin human 25 % vial 25 g (has no administration in time range)                Results for orders placed or performed during the hospital encounter of 07/30/22    SARS-CoV-2, QL, PCR (STAT)        Specimen: Nasophayngeal; Nasopharyngeal    Result   Value   Ref Range        SARS-CoV-2 RNA   Detected (A)        CBC    Result   Value   Ref Range        WBC   2.5 (L)   4.5 - 11.0 10*3/uL        RBC   2.91 (L)   4.00 - 5.20 10*6/uL        HGB   8.5 (L)   12.0 - 16.0 g/dL        HCT   25.4 (L)   33.0 - 51.0 %        MCV   87.1   80.0 - 100.0 fL        MCHC   33.5   32.0 - 36.0 g/dL        MCH   29.2   26.0 - 34.0 pg        RDW   16.5   10.7 - 18.7 %        MPV   7.1   6.5 - 10.0 fL        Platelet Cnt   106 (L)   150 - 450 10*3/uL        Differential Type   Auto            Neutrophils   72.6 (H)   35.0 - 66.0 %        Lymphocytes   13.0 (L)   24.0 - 44.0 %        Monocytes   12.9   2.1 - 13.3 %        Eosinophils   0.5   0.3 - 5.0 %        Basophils   1.0   0.0 - 1.0 %        Neutrophils Abs   1.8   1.5 - 8.5 10*3/uL        Lymphocytes Abs   0.3 (L)   1.1 - 5.0 10*3/uL        Monocytes Abs   0.3   0.0 - 1.4 10*3/uL        Eosinophils Abs   0.0   0.0 - 0.5 10*3/uL        Basophils Abs   0.0   0.0 - 0.1 10*3/uL    Comprehensive Metabolic Panel    Result   Value   Ref Range        SODIUM   138   135 - 145 mmol/L        POTASSIUM   3.8   3.6 - 5.0 mmol/L        CHLORIDE   98 (L)   101 - 111 mmol/L        CO2   25   21 - 31 mmol/L        ANION GAP   15            GLUCOSE   81   70 - 110 mg/dL        CREATININE   12.4 (HH)   0.4 - 1.0 mg/dL        BUN   40 (H)   2 - 32 mg/dL        CALCIUM   8.7   8.5 - 10.5 mg/dL        PROTEIN TOTAL   5.4 (L)   6.1 - 7.8 g/dL        Albumin   3.9   3.2 - 5.0 g/dL        T BILIRUBIN   0.6   0.2 - 1.0 mg/dL        ALP   107   42 - 121 [iU]/L        AST   71 (H)   10 - 42 [iU]/L        ALT (SGPT)   60   10 - 60 [iU]/L        OSMOLALITY   284   266 - 309        A/G Ratio   2.6            B/C   3 (L)   10 - 20        ESTIMATED GFR   3   mL/min    Pregnancy Test Serum    Result   Value   Ref Range        PREGNANCY TEST, SERUM   NEGATIVE   NEGATIVE           Results     None              Consult:  0952: I spoke with Hospitalist, about the pt's history of present illness, physical examination and course in the ED. Dr. accepts pt for admission.     0956: Case discussed with Nephrologist.      Plan:  ED RECHECK: Admit: The pt is awake and alert at time of reevaluation. I spoke with the patient about her ED work up and diagnosis. I informed the patient that she will be admitted for further evaluation/treatment. All questions answered. The pt is agreeable.      MDM  Number of Diagnoses or Management Options     Amount and/or Complexity of Data Reviewed  Clinical lab tests: ordered and reviewed  Tests in the medicine section of CPT®: ordered and reviewed  Decide to obtain previous medical records or to obtain history from someone other than the patient: yes  Obtain history from someone other than the patient: yes  Review and summarize past medical records: yes  Independent visualization of images, tracings, or specimens: yes     Risk of Complications, Morbidity, and/or Mortality  Presenting problems: moderate Diagnostic procedures: moderate Management options: moderate   Patient Progress  Patient progress: stable        Progress Note:               ED Prescriptions              None                 Final diagnoses:    Acute on chronic renal failure    COVID-19 virus infection                 ED Disposition                  ED Disposition    Admitted        Condition    --        Comment    Bed Reason: Medical Necessity [2]                                   Scribe Attestation:  acting as scribe for and in the presence  Electronically Signed 07/30/22 7:42 AM        Provider Attestation:  I personally performed the services described in the documentation, reviewed the documentation recorded by the scribe in my presence and it accurately and completely records my words and actions.   Electronically Signed 7/30/2022 6:44 PM         Electronically signed at 07/30/22 1844                   ED to Hosp-Admission (Discharged) on 7/30/2022               Revision History               Detailed Report             Note shared with patient              Care Timeline   07/30    Admitted from ED (Observation) 1201  07/31    Discharged 1219