Symptomtext
Document Type: ED Physician Progress Note Document Subject: ED Progress Note Performed By: Employee on October 29, 2022 11:08 Verified By: MD on October 29, 2022 13:54 Encounter Info: Hospital, Emergency, 10/29/22 - 10/29/22 * Final Report * Basic Information Time Seen: MD / 10/29/2022 11:00 Chief Complaint Shortness of breath (Complaint of) History of Present Illness Time Seen: 10/29/22 11:02:03 59 year old female with hx of asthma, bipolar, schizophrenia, and depression presents to the ED via private vehicle complaining of L-sided flank/abdominal pain onset 1 month ago. Pain is intermittent in nature. Pain is sharp. Worsens with inspiration. Pt endorses associated dyspnea, hematuria, and nausea. Denies emesis. Pt states she is currently being worked up by her PCP for gallstones. Pt reports previous hx of kidney stones. Pt notes she is attempting to quit. Pt is no longer on Plavix. Review of Systems Respiratory: +dyspnea Gastrointestinal: +L-sided abdominal/flank pain, +nausea, no emesis Genitourinary: +hematuria Additional review of systems information: All other systems reviewed and otherwise negative. Physical Exam/Objective Vitals & Measurements last 24 hours VITAL SIGNS Temp C: 36.4 DegC Heart Rate: 99 bpm Resp Rate: 28 br/min BP #1: 157 / 86 mmHg SpO2 (%): 93 % O2 Device: Room air Height CM: 157.5 cm Weight KG: 59.4 kg Ideal Body Weight: 50.12 kg General: Alert, no acute distress Head: Normocephalic, atraumatic Eyes: Pupils equal, round, and reactive to light, extraocular movements are intact Cardiovascular: Regular rate and rhythm, no murmur Respiratory: slight wheezing, hyperventilating which improved over the course of the interview Gastrointestinal: Soft, nontender, non-distended Musculoskeletal: Normal range of motion Neurological: Alert and oriented to person, place, time, and situation, no focal neurological deficits Medical Decision Making Rationale: Diff dx includes but not limited to: renal stone vs less likely pneumonia vs less likely diverticulitis vs gastritis vs less likely cardiogenic cause vs psychosomatic cause. Will get labs, EKG, and CXR and give pain meds. Likely dispo: discharge if workup if negative. 10/29/22 13:42:51 Rechecked pt. Updated pt on all current labs and imaging, which are not indicative of an acute abnormalities. Pt feels improved. Counselled pt on follow-up with PCP. Discussed dx and plan for discharge. Patient understands and agrees with plan. All questions addressed. Condition Stable Disposition: 10/29/22 13:42:33 discharged to home Counseled Counseled patient regarding diagnosis, regarding diagnostic results, regarding treatment plan. Patient indicated understanding of instructions. Scribe Attestation: I, acting as scribe for Dr at 10/29/22 11:02:38 Signed by Scribe, at 10/29/22 11:02:38 I, MD, have reviewed this note and attest to its contents. It was prepared under my direction and at the time of my signature I will have reviewed it in its entirety and edited where appropriate. Assessment/Plan Left flank pain R10.9 Patient Education Flank Pain, Uncertain Cause Follow Up With When Contact Information NP, FAM Within 1 to 2 weeks Healthcare Additional Instructions: Chronic Problem List Closed fracture of proximal end of left humerus Fracture of proximal end of left humerus Fracture of scaphoid of left wrist Smoker Procedure/Surgical History ?bladder surgery (2016) ?Colonoscopy (05/24/2013) ?Back ?BREAST IMPLANT REMOVAL ?HYSTERECTOMY ?Tonsillectomy Surgical History Internal 02/12/2020 Wound Debridement. MD Medications Home Medications (17) Active clopidogrel 75 mg oral tablet Depakote ER 500 mg oral tablet, extended release 500 mg = 1 Tablet, Orally, Daily DiazePAM 5 mg oral tablet gabapentin 300 mg oral capsule ibuprofen 600 mg oral tablet 600 mg = 1 Tablet, PRN, Orally, 4 Times Daily Latuda 120 mg oral tablet olanzapine 15 mg oral tablet ProAir HFA 90 mCg/inh inhalation aerosol 2 Puff, Inhalation, Q6H Santyl topical 250 Units/GM ointment See Instructions, APPLY TO THE AFFECTED AREA as directed by THE wound center Spiriva Respimat 1.25 mCg/inh inhalation aerosol traZODONE 150 mg oral tablet Trelegy Ellipta Trelegy Ellipta , Inhalation, Daily Trelegy Ellipta , Inhalation, Daily Trelegy Ellipta , Inhalation, Daily Trelegy Ellipta inhalation powder 1 Puff, Inhalation, Daily Zyprexa Medication Administration Given fentaNYL, 50 mCg, IV Push ondansetron, 4 mg, IV Push Allergies penicillins Social History Alcohol Denies Substance Abuse Denies Tobacco Tobacco Use: Current Every Day Smoker. Cigarettes, 1 packs per day. Family History Family history is unknown Lab Results Hemogram-Platelets-WBC Differential FS LATEST RESULTS WBC 10/29/22 11:22 8.3 RBC 10/29/22 11:22 4.54 Hgb 10/29/22 11:22 13.7 Hct 10/29/22 11:22 41.3 MCV 10/29/22 11:22 91 MCH 10/29/22 11:22 30.1 MCHC 10/29/22 11:22 33.1 RDW 10/29/22 11:22 14.3 Platelet 10/29/22 11:22 269 MPV 10/29/22 11:22 7.4 Neutrophils % 10/29/22 11:22 60 Lymphocytes % 10/29/22 11:22 28 Monocytes % 10/29/22 11:22 6 Eosinophils % 10/29/22 11:22 5 Basophils % 10/29/22 11:22 1 Absolute Neutrophil 10/29/22 11:22 5.0 Absolute Lymphocyte 10/29/22 11:22 2.3 Absolute Monocyte 10/29/22 11:22 0.5 Absolute Eosinophil 10/29/22 11:22 0.4 High Absolute Basophil 10/29/22 11:22 0.1 Routine Chemistry Tests FS LATEST RESULTS Sodium SerPl QN 10/29/22 11:22 135 Potassium SerPl QN 10/29/22 11:22 4.0 Chloride SerPl QN 10/29/22 11:22 101 Carbon Dioxide SerPl QN 10/29/22 11:22 27 Anion Gap 10/29/22 11:22 7 BUN SerPl QN 10/29/22 11:22 17 Creatinine SerPl QN 10/29/22 11:22 0.85 Estimated GFR (CKD-EPI, no race) 10/29/22 11:22 79 Estimated CRCL (CG) 10/29/22 11:22 61 Glucose SerPl QN 10/29/22 11:22 94 Calcium Total SerPl QN 10/29/22 11:22 10.3 Alkaline Phos SerPl QN 10/29/22 11:22 70 ALT SerPl QN 10/29/22 11:22 10 AST SerPl QN 10/29/22 11:22 13 Bilirubin Total SerPl QN 10/29/22 11:22 0.3 Total Protein SerPl QN 10/29/22 11:22 7.1 Albumin SerPl QN 10/29/22 11:22 4.4 Troponin-I High Sensitivity 10/29/22 11:22 3 Urinalysis FS LATEST RESULTS Color 10/29/22 12:46 Yellow Clarity 10/29/22 12:46 Clear Specific Gravity 10/29/22 12:46 1.010 pH 10/29/22 12:46 6.5 Protein 10/29/22 12:46 Negative Glucose 10/29/22 12:46 Negative Ketones 10/29/22 12:46 Negative Bilirubin 10/29/22 12:46 Negative Hgb Ur 10/29/22 12:46 Negative Nitrite 10/29/22 12:46 Negative Urobilinogen 10/29/22 12:46 Normal Leukocyte Esterase Ur 10/29/22 12:46 Trace Abnormal Molecular Diagnostic Tests LATEST RESULTS COVID 19 Specimen Source 10/29/22 11:22 Nasal Coronavirus SARS-CoV2 Rapid 10/29/22 11:22 Not Detected Diagnostic Results CT Abd/Pelvis W/O IV Contrast 10/29/22 11:59:02 IMPRESSION: 1. No acute findings in the abdomen or pelvis. Thank you for consulting our team of subspecialty radiologists at Radiology. Healthcare providers wishing to discuss this case further can contact the Abdominal Imaging Reading Room. For after-hours or emergency department cases, please call Electronically Signed by: Signed By: MD ************************************************** XR Chest PA or AP Portable 10/29/22 11:39:15 IMPRESSION: 1. No acute findings in the chest. Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discuss this case further can contact the Cardiothoracic Reading Room. For after-hours or emergency department cases, please call . Electronically Signed by: Signed By: MD EKG Time: 10/29/2022 1054 Rate: 73 bpm Rhythm: normal sinus rhythm Intervals: within normal limits EP Interp: no acute ischemic findings Signature Line Electronically Signed on 10/29/22 13:45 ________________________________________________________ Electronically Signed on 10/29/22 13:54 ________________________________________________________ MD