* Final Report * ED Triage Entered On: 01/16/2014 8:45 EST Performed On: 01/16/2014 8:42 EST by

Transcription

1 Result date: Result status: 16 January :42 EST Auth (Verified) * Final Report * ED Triage Entered On: 01/16/2014 8:45 EST Performed On: 01/16/2014 8:42 EST by Assessment I Chief Complaint : Diarrhea x 3-4 days, denies pain, hx of same with dehydration, hx of celiac IV Field Start : No Affect/Behavior : Anxious Pain Scale Type : 0-10 Pain scale Primary Pain Intensity : 0 Allergies Reviewed : Yes Oxygen Therapy : Room air Temperature Oral : 98.3 DegF(Converted to: 36.8 DegC) Peripheral Pulse Rate : 109 bpm (HI) Respiratory Rate : 18 br/min Systolic Blood Pressure : 106 mmhg Diastolic Blood Pressure : 55 mmhg (LOW) SpO2 : 95 % Dosing Weight : (R) Patient Weight : Stated Height : Assessment II Pregnancy Status : N/A Fall Risk Order Detail : No Preferred Language to Discuss Healthcare : English ED Suspected Infection : No Dx Control/PMH Problems(Active) Syncope (SNOMED CT : ) (As Of: 01/16/ :45:49 EST) Name of Problem: Syncope ; Recorder: Confirmation: Confirmed ; Classification: Medical ; Code: ; Contributor System: PowerChart ; Last Updated: 05/24/ :14 EDT ; Life Cycle Date: 05/24/2009 ; Life Cycle Status: Active ; Vocabulary: SNOMED CT ESI Requires immediate life-saving interventions? : No ESI High Risk, Altered LOC, Distressed : No How many different resources are needed? : Many ESI vital sign alert : No ESI recommended level : 3 ESI clinical agreement : Yes DCP GENERIC CODE Tracking Specialty : Main ED Tracking Acuity : 3 Tracking Group : ED Tracking Group

2 Allergy Allergies (Active) NKA Estimated Onset Date: Unspecified ; Created By: Reaction Status: Active ; Category: Drug ; Substance: NKA ; Type: Allergy ; Updated By: Date: 12/30/ :03 EST (As Of: 01/16/ :45:49 EST)

3 Result date: Result status: 16 January :52 EST Auth (Verified) Abdominal Complaint Patient: Age: 70 years Sex: Female DOB Author: Attachments: None Basic Information Time seen: Date & time 01/16/ :49:00. Additional information: Chief Complaint from Nursing Triage Note : Chief Complaint. 01/16/2014 8:42 EST Chief Complaint Diarrhea x 3-4 days, denies pain, hx of same with dehydration, hx of celiac History of Present Illness The character of symptoms is unknown. patient presents emergency Department with complaints of diarrhea and nausea over the past 4 days described as nonbloody thin stool. Patient denies any fevers or chills denies any travel or known exposure. The patient had similar episode in the past was diagnosed with celiac and was on a low gluten diet for a short period time but is gone back to a normal diet. Review of Systems Constitutional symptoms: Negative except as documented in HPI. Skin symptoms: No rash, no petechiae or no lesion. Eye symptoms: Diplopia. Respiratory symptoms: No shortness of breath or no cough. Cardiovascular symptoms: No chest pain or no syncope. Genitourinary symptoms: No dysuria. Musculoskeletal symptoms: No Muscle pain or no Joint pain. Neurologic symptoms: No headache, no dizziness or no weakness. Psychiatric symptoms: No anxiety or no depression. Endocrine symptoms: No polyuria or no polydipsia. Hematologic/Lymphatic symptoms: Bleeding tendency negative. Health Status Allergies:. Allergic Reactions (All) NKA Medications: (Selected). Prescriptions Prescribed Benicar 20 mg oral tablet: 20 mg = 1 tab, Oral, Tablet, qday, # 30 tab, 0 Refill(s), Pharmacy: hydrochlorothiazide 12.5 mg oral capsule: 12.5 mg = 1 cap, Oral, Capsule, qday, # 30 cap, 0 Refill(s), Pharmacy: Documented Medications Documented Lipitor 20 mg oral tablet: 20 mg, 1 tab, PO, qhs, 0, 0 Past Medical/ Family/ Social History Problem list:. All Problems Syncope / / Confirmed Inactive: HTN - Hypertension / Inactive: Hypercholesterolemia / Surgical history: Negative. Family history: Not significant,. No family history items have been selected or recorded. Social history: Alcohol use: Denies, Tobacco use: Denies, Drug use: Denies. Physical Examination Vital Signs

4 Vital Signs. 01/16/2014 8:42 EST Temperature Oral 98.3 DegF Peripheral Pulse Rate 109 bpm HI Respiratory Rate 18 br/min Systolic Blood Pressure 106 mmhg Diastolic Blood Pressure 55 mmhg LOW SpO2 95 % General: Moderate distress. Skin: Warm and dry. Head: Normocephalic. Neck: Supple, trachea midline and no JVD. Eye: Pupils are equal, round and reactive to light and extraocular movements are intact. Ears, nose, mouth and throat: Tympanic membranes clear and oral mucosa moist. Cardiovascular: Regular rate and rhythm, No murmur and No edema. Respiratory: Lungs are clear to auscultation. Gastrointestinal: abdomen is soft bowel sounds are functional no tenderness guarding or rebound. Musculoskeletal: Normal ROM, no tenderness, no swelling and no deformity. Neurological: Alert and oriented to person, place, time, and situation, CN II-XII intact, normal sensory observed and normal motor observed. Lymphatics: No lymphadenopathy. Psychiatric: Cooperative and appropriate mood & affect. Medical Decision Making Differential Diagnosis:Dehydration, influenza, viral syndrome, celiac disease. Documents reviewed:emergency department nurses' notes, emergency department records, prior records. Electrocardiogram:Rate 90, normal sinus rhythm, no ectopy, normal PR & QRS intervals, EP Interp, poor R-wave progression but unchanged from previous EKG of December Results review:lab results : Lab View. 01/16/ :17 EST WBC 8.2 thous/mm3 RBC 4.65 mill/mm3 HGB 14.7 g/dl HCT 43.4 % MCV 93.4 fl MCH 31.7 pg HI MCHC 33.9 g/dl RDW 12.8 % Platelet 419 thous/mm3 MPV 7.4 fl Gran % 74.3 % HI Lymph % 15.3 % LOW Mono % 9.4 % Eos % 0.6 % Baso % 0.4 % Gran # 6.1 thous/mm3 Lymph # 1.3 thous/mm3 LOW Mono # 0.8 thous/mm3 Eos # 0.0 thous/mm3 Baso # 0.0 thous/mm3 Sodium Level 142 mmol/l Potassium Level 3.5 mmol/l Chloride 105 mmol/l CO2 21 mmol/l LOW Anion Gap 16 mmol/l HI Glucose Level 110 mg/dl HI BUN 18 mg/dl Creatinine 1.05 mg/dl HI egfr 52 ml/min LOW egfr Afri-Amer >60 ml/min Calcium Level 8.9 mg/dl

5 Total Protein 6.3 g/dl Albumin Level 3.8 g/dl Bili Total 0.6 mg/dl ALT 47 IntUnit/L AST 32 IntUnit/L Alk Phos 64 IntUnit/L Lipase Level 62 IntUnit/L 01/16/2014 9:55 EST UA Spec Grav UA ph 6.0 UA Leuk Est Negative UA Nitrite Negative UA Protein Trace UA Ketones Trace UA Glucose Negative UA Bili See Comment UA Urobilinogen 0.2 mg/dl UA Blood Negative 01/16/2014 9:54 EST Lactic Acid 1.8 mmol/l Notes:patient was evaluated shortly after arrival in the emergency department was given fluid hydration. Her lab workup was negative and she is tolerating by mouth fluids well. She will be discharged with diagnosis of possible gastroenteritis versus celiac and urged to stay on clear liquid diet with low gluten and followup with her primary care provider to return to the emergency department worsening pain fever or vomiting. Reexamination/ Reevaluation Course: improving. Assessment: exam improved. Impression and Plan Plan Condition: Improved. Disposition: Discharged: to home. Patient was given the following educational materials: GASTROENTERITIS, Non-Infectious [6y-Adult], DIET, Clear Liquid. Follow up with: Counseled: Patient, Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Patient indicated understanding of instructions.