Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on July 25, 2023 06:47    Verified By: MD on July 25, 2023 06:47   Encounter Info: Hospital, Observation, 07/24/23 -     * Final Report *        Chief Complaint   Flank pain  History of Present Illness/Subjective     27-year-old female with past medical history of drug use, depression, diabetes mellitus, recent subarachnoid hemorrhage and E. coli bacteremia due to pyelonephritis presents with urgency and pain on urination for 3 days.  The patient was admitted here for 5 days and discharged on July 11, at that time she was discharged to complete a prolonged course of cefpodoxime for which she states compliance.  Prior history   -Patient was admitted in March 2023 and again in April 2023.  History of E. coli UTI with resistance, bacteremia.   -Patient was then admitted from 4/29 to 5/3 after a fall.  She was at OSH found to be in DKA, AKI and bilateral subarachnoid hemorrhage.  She was transferred and treated for E. coli bacteremia due to bilateral pyelonephritis.  ID was consulted.  She was recommended to get IV ceftriaxone for 7 days and switch to cefpodoxime to finish total of 10 days of antibiotics.  However she left AMA on fifth day of ceftriaxone.  ? Neurosurgery was consulted during the hospital stay  for the subarachnoid hemorrhage and recommended conservative management.  Okay for chemical DVT prophylaxis   Flank pain, dysuria, chills.  She has history of using meth but denies any IV drugs   Recently seen by urology, suspected etiology for recurrent pyelonephritis not related to structural abnormality, instead, diabetes.   At this time, mild leukocytosis, mildly elevated creatinine, normal LFTs, blood sugar only 121, pregnancy test negative, urine was obtained that showed trace bacteria, nitrite positive, l leukocyte esterase positive, however, there were many squamous epithelial cells this is test is not reliable.  Review of Systems     Complains of flank pain, urinary frequency, dysuria, no fever or chills, remaining 10 point review of systems negative except as noted above.  Otherwise, sleepy, somewhat unenthusiastic about cooperating.  She apparently refused Tylenol in the emergency department.  She actually would only provide very brief answers and was very disinterested, the above is as reliable as we can hope  Physical Exam/Objective Vitals & Measurements most recent past 24 hours  T: 37 °C (Oral)  TMIN: 36.8 °C (Oral)  TMAX: 37 °C (Oral)  BP: 98/71  HR: 97 (Monitored)  RR: 14  SpO2: 99%  Oxygen Therapy: Room air  Oxygen Flow Rate: 0 (L/min)  WT: 66 kg  BMI: 25   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    66 kg    07/25/23  Previous Daily Weight:    68.1 kg    07/25/23  Difference from Previous:    -2.100000 kg  BMI:    25    07/25/23    Overweight (BMI 25-29.9) Patient Height  Current Height:    165.1 cm    07/25/23        Constitutional:  No acute distress nontoxic Eyes:  PERRLA, 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, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no focal deficits    Assessment/Plan       1. Recurrent pyelonephritis   N12  Given resistance patterns and failure of treatment with beta-lactam, we will continue gentamicin.  Follow urine cultures and blood cultures.  While tachycardic, technically does not meet SIRS criteria.  Additionally, hemodynamically stable and hypertensive.  IV fluids.  Monitor hemodynamics closely.   2. Intellectual disability   F79  Noted   3. DM (diabetes mellitus), type 1, uncontrolled   E10.65  Basal and bolus insulin, diabetic diet, Accu-Cheks   4. IDA (iron deficiency anemia)   D50.9  Supplemental iron   Lovenox for anticoagulation   Full code  Code Status   Full Code   Chronic Problem List    Bacteremia  Biliary dyskinesia  Depression  DM (diabetes mellitus), type 1, uncontrolled  Dysfunctional uterine bleeding  Folliculitis  Genital herpes  Genital herpes in women  Heavy menses  IDA (iron deficiency anemia)  Intellectual disability  Long term use of drug  Low back pain  Low back pain syndrome  Nausea  Pyelonephritis  Recurrent genital herpes  Recurrent pyelonephritis  Recurrent UTI  Right knee pain  Screen for STD (sexually transmitted disease)  Sepsis  Severe sepsis without septic shock  Unstable type 1 diabetes mellitus  UTI (urinary tract infection)  Procedure/Surgical History  ?lap tuball ligation (04/23/2018) ?Cesarean section (2014) ?Tooth extraction (2013)   Surgical History Internal  08/12/2019    Hysteroscopy Diagnostic    DO  09/19/2018    Cholecystectomy Laparoscopic    MD  04/23/2018    Tubal Clips Laparoscopic    DO  Medications   Home Medications (24) Active  Accu-Chek Guide Blood Glucose Meter Not Applicable, Other, Unscheduled  Accu-Chek Guide Test Strips Check up to 4 times daily, Other, Unscheduled  Accu-Chek Softclix Lancets Check up to 4 times daily, Other, Unscheduled, Dispense QS 90 days  acetaminophen 325 mg oral tablet 650 mg = 2 Tablet, PRN, Orally, Q4H  Ascensia Bayer Blood Glucometer Elite XL Not Applicable, Other, Unscheduled  Ascensia Bayer Blood Glucometer Elite XL Not Applicable, Other, Unscheduled  BD Ultra-Fine Nano (4mm x 32G) Pen Needle Use 4 per day, Other, Unscheduled, Pen Needlesuse with insulin  BD Ultra-Fine Nano (4mm x 32G) Pen Needle Use 4 per day, Other, 4 Times Daily, Dispense QS for 30 days  cefPODOXime 200 mg oral tablet 200 mg = 1 Tablet, Orally, BID  ferrous sulfate 325 mg (65 mg elemental iron) oral tablet 325 mg = 1 Tablet, Orally, Daily  FreeStyle Libre 2 Glucose Reader Not Applicable, Other, Unscheduled, E10.65  FreeStyle Libre 2 Sensors Use As Directed, Misc, Unscheduled, E10.65  gabapentin 100 mg oral capsule , TAKE 2 CAPSULES THREE TIMES DAILY FOR 3O DAYS  Glucometer Elite Test Strips Check up to 4 times daily, Other, Unscheduled, Dispense QS 90 days  insulin glargine 100 units/mL subcutaneous solution 42 Units, Subcutaneous, Daily  Ketostix Reagent Strips In Foil See Instructions, Use as Directed Other Unscheduled  Lancets Check up to 6 times daily, Other, Unscheduled, Dispense QS 90 days  nitrofurantoin macrocrystals 100 mg oral capsule 100 mg = 1 Capsule, Orally, Daily  NovoLOG (insulin aspart) FlexPen 100 units/mL subcutaneous solution See Instructions, subcutaneous for 30 days  paliperidone 3 mg oral tablet, extended release , TAKE 1 TABLET BY MOUTH DAILY IN THE MORNING  prazosin 1 mg oral capsule , TAKE 1 CAPSULE BY MOUTH AT BEDTIME  promethazine 25 mg oral tablet 25 mg = 1 Tablet, PRN, Orally, Q6H  Syringes - Insulin 1/2 mL See Instructions, Use 3 time daily with Humalog. Please dispense 6 mm, 1/2 mL insulin syringes x 90 days.  VALAcyclovir 500 mg oral tablet   Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 07/24/23 00:00:00 TO 07/25/23 06:47:33  acetaminophen (Tylenol), Tablet, 1,000 mg, Orally, ONCE, Ordered NOT yet givengentamicin, Injection, 300 mg, IVPB, ONCE, (1 DOSE 07/25/23 01:10:00)  Lactated Ringers (LR - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 07/25/23 00:18:00)  PRN Medications (0600 - 0559) from 07/24 - 07/25  None Reported  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use 1-25 inhales/day.   Substance Abuse   Past, Methamphetamines   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Hypertension: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Chemistry:  Sodium SerPl QN: 142 mmol/L (07/24/23 20:16:00)  Potassium SerPl QN: 4.4 mmol/L (07/24/23 20:16:00)  Chloride SerPl QN: 104 mmol/L (07/24/23 20:16:00)  Carbon Dioxide SerPl QN: 27 mmol/L (07/24/23 20:16:00)  Anion Gap: 11 mmol/L (07/24/23 20:16:00)  BUN SerPl QN: 12 mg/dL (07/24/23 20:16:00)  Creatinine SerPl QN: 1.24 mg/dL High (07/24/23 20:16:00)  Estimated GFR (CKD-EPI, no race): 61 mL/min/1.73m2 (07/24/23 20:16:00)  Estimated CRCL (CG): 66 mL/min (07/24/23 20:16:00)  Glucose SerPl QN: 121 mg/dL High (07/24/23 20:16:00)  Calcium Total SerPl QN: 9.5 mg/dL (07/24/23 20:16:00)  Alkaline Phos SerPl QN: 85 Units/L (07/24/23 20:16:00)  ALT SerPl QN: 9 Units/L (07/24/23 20:16:00)  AST SerPl QN: 18 Units/L (07/24/23 20:16:00)  Bilirubin Total SerPl QN: 0.3 mg/dL (07/24/23 20:16:00)  Total Protein SerPl QN: 7 GM/dL (07/24/23 20:16:00)  Albumin SerPl QN: 3.6 GM/dL (07/24/23 20:16:00)  Ketones SerPl QN: Negative (07/24/23 22:57:00)  pH Bld Venous QN: 7.6 High (07/24/23 20:16:00)  Patient Temperature: 37 DegC (07/24/23 20:16:00)  Urine Studies:  Pregnancy Test Urine: Negative (07/24/23 20:24:00)  Color: Light-Yellow (07/24/23 20:24:00)  Clarity: Cloudy (07/24/23 20:24:00)  Specific Gravity: 1.006 (07/24/23 20:24:00)  pH: 6 (07/24/23 20:24:00)  Protein: 70 Abnormal (07/24/23 20:24:00)  Glucose: 150 Abnormal (07/24/23 20:24:00)  Ketones: NEGATIVE (07/24/23 20:24:00)  Bilirubin: NEGATIVE (07/24/23 20:24:00)  Hgb Ur: Large 3+ Abnormal (07/24/23 20:24:00)  Nitrite: Positive 1+ Abnormal (07/24/23 20:24:00)  Urobilinogen: Normal (07/24/23 20:24:00)  Leukocyte Esterase Ur: Large500 Abnormal (07/24/23 20:24:00)  WBC: >100 Abnormal (07/24/23 20:24:00)  RBC: 51-100 Abnormal (07/24/23 20:24:00)  WBC Clumps: PRESENT. Abnormal (07/24/23 20:24:00)  Bacteria: TRACE. (07/24/23 20:24:00)  Squamous Epithelial: Many (07/24/23 20:24:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.             Signature Line Electronically Signed on 07/25/23 06:47  ________________________________________________________ MD