Document Type: History and Physical Document Subject: History & Physical Note Performed By: MD on January 20, 2025 13:46 Verified By: MD on January 20, 2025 13:46 Encounter Info: Hospital, Inpatient, 01/20/25 – * Final Report * Chief Complaint Diarrhea History of Present Illness/Subjective Patient is an 83 year old woman who presents to the ER w/ diarrhea and abd pain for the last 3 days. Patient endorses watery diarrhea, no blood. She has also had abd pain and increased urinary frequency. She denies any fever. Upon arrival to the ER she was tachycardic and afebrile. BP was 91/60. Labs were notable for a WBC count of 12. Hgb was 11. Na was 129 and Cr was 2.6. CT abd/pelvis showed e/o colitis. Lactate was 2.3 but repeat was normal. Patient was given fluids and admitted to the medicine service for further management. Review of Systems With the exception of that noted in the HPI all systems were reviewed and were negative. Physical Exam/Objective Vitals & Measurements most recent past 24 hours Constitutional: No acute distress, well-nourished Eyes: no scleral icterus ENMT: Moist oral mucosa Respiratory: CTAB Cardiovascular: Regular rate and rhythm, no MGR Gastrointestinal: non-distended, tender to palpation Musculoskeletal: intact ROM Integumentary: no rashes Neurologic: no focal deficits Psychiatric: Cooperative, appropriate mood and affect Assessment/Plan 1. Colitis K52.9 -Unclear cause -GIP panel -GI consult -Zosyn 2. AKI (acute kidney injury) N17.9 -Pre-renal in nature -LR at 100cc/hr -PVR urine -Renally dose meds 3. Dehydration E86.0 -Fluids as above 4. Hyponatremia E87.1 -The patient presents with a electrolyte imbalance including hypo-osmolality and hyponatremia. Continue to trend serial analysis as appropriate with replenishment of electrolyte imbalance as required for stabilization. -Hypovolemic -Fluids as above 5. Anemia D64.9 -The patient presents with anemia chronic and normocytic due to other chronic disease at present is stable. Continue to trend serial analysis as appropriate with nutritional or blood product supplementation as required. 6. Leukocytosis D72.829 -Non-specific finding -Likely due to colitis 7. GERD (gastroesophageal reflux disease) K21.9 -Continue PPI 8. Hyperlipidemia E78.5 -Continue statin Code Status Full Code Chronic Problem List Acute respiratory failure Anemia Cervical radiculopathy CKD (chronic kidney disease), stage II COPD (chronic obstructive pulmonary disease) COPD bronchitis COVID DDD (degenerative disc disease), cervical DDD (degenerative disc disease), lumbar GERD (gastroesophageal reflux disease) Goiter Hematuria History of peptic ulcer Hyperlipidemia Hypoalbuminemia Long term use of drug Lumbar radiculopathy Lung nodule Osteoarthritis Osteopenia PE (pulmonary thromboembolism) Pneumonia Postmenopausal Reactive thrombocytosis Smoking Thrombocytosis UTI (urinary tract infection) Procedure/Surgical History ?Back surgery (07/17/2024) ?colonoscopy (05/15/2014) ?small bowel capsule (04/29/2014) ?egd (04/24/2014) ?back surgery (05/2010) ?abdominal laparotomy multiple times ?c-section ?cataract removal with lens implants ?goiter removed from neck ?hysterectomy ?lumbar surgery ?rotator cuff repair right shoulder Surgical History Internal 06/17/2024 Spine Fusion Posterior Lumbar (Postr) MD 04/02/2018 Spine Fusion Posterior Lumbar MD 03/07/2016 Lumbar Laminectomy (Left) MD Medications Home Medications (10) Active albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q6H, COPD atorvastatin 20 mg oral tablet 20 mg = 1 Tablet, Orally, QHS DME (Vendor) Oxygen See DME Order Details or printed requisition for more information., This is a print requisition order, cannot be ePrescribed. DULOXetine 30 mg oral delayed release capsule 30 mg = 1 Capsule, Orally, Daily, TAKE 1 CAPSULE BY MOUTH DAILY gabapentin 100 mg oral capsule 100 mg = 1 Capsule, Orally, 4 Times Daily hydroxyurea 500 mg oral capsule 1 Capsule, Orally, Daily Magic Potion oral solution 5 mL, Orally, 4 Times Daily, Swish and Spit montelukast 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily OXYcodone-acetaminophen 7.5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, Q4H pantoprazole 40 mg oral delayed release tablet 40 mg = 1 Tablet, Orally, Daily Active Scheduled Inpatient Medications Sodium Chloride 0.9% 500 mL IV Continuous 42 mL/hr Days 1, 8 One-Time Medications Given 01/19/25 00:00:00 TO 01/20/25 13:41:14 None Reported PRN Medications (0600 – 0559) from 01/19 – 01/20 None Reported Allergies Eggs (Blisters) No Known Medication Allergies Social History Alcohol Denies Electronic Cigarette/Vaping E-Cigarette Use Never. Home/Environment Lives with Spouse, 35YR OLD GRANDSON. Nutrition/Health Diet: Regular. Substance Abuse Denies Tobacco Tobacco Use: Former smoker, quit more than 30 days ago. Started age 16.0 Years. Stopped age 83 Years. Family History Breast cancer: Mother. Cancer of colon: Daughter. Diabetes mellitus type 2: Mother. Heart attack..: Mother. Prostate cancer..: Father. Deceased Family Member(s) Relationship: Mother, Age: Unknown, Cause: DM, CA of breast, heart Relationship: Father, Age: Unknown, Cause: Bladder CA, Prostate CA then to Bone Lab Results All Labs Last 24 hours (No Micro or Pathology) Hematology: WBC: 12 k/cumm High (01/20/25 08:08:00) RBC: 3.24 million/cumm Low (01/20/25 08:08:00) Hgb: 11.8 GM/dL Low (01/20/25 08:08:00) Hct: 35.6 % (01/20/25 08:08:00) MCV: 110 fL High (01/20/25 08:08:00) MCH: 36.5 pg High (01/20/25 08:08:00) MCHC: 33.2 GM/dL (01/20/25 08:08:00) RDW: 24.1 % High (01/20/25 08:08:00) Platelet: 212 k/cumm (01/20/25 08:08:00) MPV: 8.5 fL (01/20/25 08:08:00) Neutrophils %: 94 % (01/20/25 08:08:00) Lymphocytes %: 3 % (01/20/25 08:08:00) Monocytes %: 3 % (01/20/25 08:08:00) Eosinophils %: 0 % (01/20/25 08:08:00) Basophils %: 0 % (01/20/25 08:08:00) Absolute Neutrophil: 11.3 k/cumm High (01/20/25 08:08:00) Absolute Lymphocyte: 0.4 k/cumm Low (01/20/25 08:08:00) Absolute Monocyte: 0.4 k/cumm (01/20/25 08:08:00) Absolute Eosinophil: 0 k/cumm (01/20/25 08:08:00) Absolute Basophil: 0 k/cumm (01/20/25 08:08:00) Chemistry: Sodium SerPl QN: 129 mmol/L Low (01/20/25 08:08:00) Potassium SerPl QN: 5.5 mmol/L (01/20/25 08:08:00) Chloride SerPl QN: 95 mmol/L Low (01/20/25 08:08:00) Carbon Dioxide SerPl QN: 25 mmol/L (01/20/25 08:08:00) Anion Gap: 9 mmol/L (01/20/25 08:08:00) BUN SerPl QN: 60 mg/dL High (01/20/25 08:08:00) Creatinine SerPl QN: 2.63 mg/dL High (01/20/25 08:08:00) Estimated GFR (CKD-EPI, no race): 18 mL/min/1.73m2 Low (01/20/25 08:08:00) Estimated CRCL (CG): 9 mL/min Low (01/20/25 08:08:00) Glucose SerPl QN: 175 mg/dL High (01/20/25 08:08:00) Calcium Total SerPl QN: 7.4 mg/dL Low (01/20/25 08:08:00) Alkaline Phos SerPl QN: 92 Units/L (01/20/25 08:08:00) ALT SerPl QN: 15 Units/L (01/20/25 08:08:00) AST SerPl QN: 47 Units/L High (01/20/25 08:08:00) Bilirubin Direct SerPl QN: <0.1 (01/20/25 08:08:00) Bilirubin Total SerPl QN: 0.6 mg/dL (01/20/25 08:08:00) Total Protein SerPl QN: 5.1 GM/dL Low (01/20/25 08:08:00) Albumin SerPl QN: 2.5 GM/dL Low (01/20/25 08:08:00) Magnesium SerPl QN: 1.8 mg/dL (01/20/25 08:08:00) Lipase SerPl QN: 4 Units/L Low (01/20/25 08:08:00) Lactate Venous Pl QN: 1.4 mmol/L (01/20/25 11:09:00) All Other Labs: COVID 19 Specimen Source: Nasal (01/20/25 08:29:00) Coronavirus SARS-CoV2 Rapid: Not Detected (01/20/25 08:29:00) Micro - Last 7 days Rapid Influenza Method: PCR - Liat (01/20/25 08:29:00) Rapid Influenza A PCR: Not Detected (01/20/25 08:29:00) Rapid Influenza B PCR: Not Detected (01/20/25 08:29:00) Diagnostics Radiology Results - Last 24 hours Across Visits 01/20/2025 09:17 - CT Abd/Pelvis W/O IV Contrast IMPRESSION: 1. Status post cholecystectomy and hysterectomy and probablyprevious hiatal hernia repair.2. Mild ascites.3. Bilateral nonobstructing nephrolithiasis.4. Diffuse wall thickening of the colon and rectum consistent withcolitis. Signature Line Electronically Signed on 01/20/25 13:46 ________________________________________________________ MD