Internal Medicine H&P 3

05/18/21

 

Identifying Information:

Name: DS

Age: 28

Sex: female

Location: NYPQ Internal Medicine

Date: 05/18/2021

Source of referral: self

Source of Information: self

Mode of Transportation: Ambulance

 

Chief Complaint: fever, headache, loss of taste x 4 days

 

History of Present Illness:

DS is a 28 y/o Hispanic female with no PMH who presented to the ED with 4 days of fever, headache, loss of taste. Patient stated that 4 days ago she started running a fever, had chills and a headache overnight, and lost sense of taste. The fever has been subjective, patient did not measure temperature. Patient also reports nausea, 3 episodes of vomiting per day for the last 3 days, one episode of diarrhea, mild body aches and dry cough. Vomiting was described as non-bloody and non-bilious. Patient stated that she smokes cannabis every few days and had a similar episode of vomiting and diarrhea one month prior. Patient last smoked 5 days prior, usual amount. LMP 05/06/21. Patient denied sick contacts, recent travel. Patent denied SOB, chest pain, abdominal pain, blood in the stool or urine, dysuria, flank pain, dizziness, weakness. Patient was evaluated in ED and admitted to medicine for cyclical vomiting and positive Covid.

 

Past Medical History

Present illness:

• Denies

 

Hospitalizations:

•  Denies

 

Past Surgical History:

• Denies

 

Home medications:

• denies

 

Allergies:

• NKDA

 

Immunizations:

• Influenza vaccine 12/2020
• Childhood immunizations up to date

 

Social History:

• Habits: admits to cannabis use a few times per week and occasional alcohol use. Denies tobacco, other substance use.
• Sexual history: sexually active, uses barrier protection, denies history of STIs.
• Marital status: single, living alone.

Family History:

• Patient unsure about family history.

 

Review of Systems:

General: admits to fever, chills, loss of taste for 4 days. Denies night sweats, weakness, fatigue,  recent weight loss/gain.

Skin, hair, nails: denies changes in texture, excessive dryness/sweating, discolorations, pigmentation, moles, rashes, pruritus, changes in hair distribution.

Head: admits headache for 4 days, denies dizziness, trauma, loss of consciousness.

Eyes: Denies visual disturbance, lacrimation, photophobia, pruritus. Unable to recall last eye exam.

Ears: denies deafness, pain, discharge.

Nose/sinuses: denies discharge, epistaxis, obstruction.

Mouth/throat: Denies bleeding gums, sore throat, ulcers, voice changes. Unable to recall last dental exam.

Neck: denied swelling, lumps, stiffness, decreased range of motion.

Pulmonary: admits to cough x 4 days. Denies SOB, dyspnea, wheezing, hemoptysis, cyanosis, orthopnea, PND.

Cardiovascular: Denies chest pain, palpitations, edema, syncope, known heart murmur.

Gastrointestinal: admits to nausea, vomiting, diarrhea x 4 days. Denies change in appetite, constipation, pyrosis, dysphagia, flatulence, abdominal pain, blood in stool.

Genitourinary: denies frequency, urgency, incontinence, dysuria, nocturia, oliguria, hematuria, STIs. LMP 05/05/21.

Musculoskeletal: admits to generalized body aches x 3 days. Denies deformity, redness, arthritis, edema.

Peripheral vascular: Denies varicose veins, peripheral edema, intermittent claudication, coldness, trophic changes, color changes.

Hematologic: denies history of anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.

Endocrine: denies polyuria, polydipsia, polyphagia, heat/cold intolerance, goiter, hirsutism.

Nervous system: Denies weakness, seizures, loss of consciousness, numbness, paresthesia, loss of strength.

Psychiatric: denies depression, anxiety, sadness, seeing a mental health professional.

 

 

Physical Exam

Vital signs:

• BP: 107/71
• HR: 65 regular
• RR: 18 unlabored
• Temp: 36.8 C
• SpO2: 100% on RA
• Height: 167.6 cm
• Weight: 72.6 kg
• BMI: 25.8

General: patient is A&OX3, in no acute distress, appears stated age.

Skin: warm, moist. No cyanosis, lesions, rashes.

Nails: no clubbing, capillary refill <2 sec throughout.

Hair: average quantity and distribution.

Head: normocephalic, atraumatic, nontender to palpation.

Eyes: symmetrical OU without evidence of strabismus or ptosis. EOM intact with nystagmus, PERRLA, full visual fields, no conjunctival pallor, no scleral icterus.

Ears: symmetrical without obvious masses, lesions, deformities, trauma, discharge, foreign bodies. TMs pearly white, intact, light reflex in appropriate position AU. Auditory acuity intact to whispered voice AU.

Nose: Nares patent bilaterally. Nasal mucosa pink and well-hydrated. Septum midline without lesions, deformities, injections, perforation. No evidence of foreign bodies.

Sinuses: nontender to palpation over bilateral frontal and maxillary sinuses.

Mouth/pharynx: lips pink, well-hydrated, no cyanosis or lesions. Oral mucosa pink, well-hydrated, no masses, lesions. Good dentition. Oropharynx without lesions, masses. Tonsils present without injection or exudate. Uvula pink, midline, without edema or lesions.

Neck: trachea midline. No masses, pulsations, lesions. Supple, nontender to palpation. Full range of motion. Thyroid nontender, no palpable masses, no thyromegaly.

Chest: symmetrical, nontender to palpation, no deformities.

Heart: regular rate and rhythm. Normal S1, S2, no S3/S4, no friction rubs, murmurs or gallops. Carotid pulses 2+ bilaterally without bruits.

Lungs: no rales, no rhonchi, no wheezing, breath sounds equal bilaterally, no accessory muscle use.

Abdomen: flat and symmetrical, soft, nontender to palpation. Bowel sounds present, hyperactive. No pulsations, bruising, masses, lesions, rebound, guarding. No CVA tenderness.

Genitourinary: deferred.

Rectal: deferred.

Musculoskeletal: no soft tissue swelling, erythema, ecchymosis, atrophy, deformities. Nontender to palpation, no crepitus. FROM in all upper and lower extremities.

Peripheral vascular: Extremities normal in color, temperature, size. Pulses 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis, stasis, ulcerations, edema.

Neurologic: A&O to person, place, and time. CNs II – XII intact. FROM without rigidity or spasticity. Normal muscle bulk and tone. No atrophy, tics, fasciculations. Strength 4/5 throughout. Normal gait, no ataxia. Sensory intact, reflexes 2+ throughout. No nuchal rigidity.

 

Labs:

• Na+ 140
• K+ 3.9
• Cl- 105
• CO2 22
• BUN 6.4
• Cr 0/67
• Ca2+ 9.6
• Glucose 94
• BUN/Cr 10
• Lipase 35
• Lactate 1.9
• LFT WNL
• WBC 3.16
• Hgb 13
• Hct 38.6
• Plt 1276
• RBC 4.2
• Neutrophils 49
• Lymphocytes 40.20
• Monocytes 9.8
• Eosinophils 0.6
• Basophils 0.3
• Influenza A: negative
• Influenza B: negative
• RSV: negative
• HCG: negative
• Urine amphetamines: negative
• Urine barbiturates: negative
• Urine benzodiazepine: negative
• Urine cannabinoid: positive
• Urine opiates: negative
• Urine cocaine: negative
• Urine color:  yellow, clear
• Urine glucose: negative
• Urine bilirubin: negative
• Urine ketones: 40
• Urine specific gravity: 1.016
• Urine blood: negative
• Urine protein: negative
• Urine urobilinogen: negative
• Urine nitrite: negative
• Urine leukocyte esterase: negative
• Urine pH: > 9.0

 

Imaging:

• CXR 2 views: no acute pulmonary disease
• CT abdomen/pelvis w/ contrast: non-distended colon demonstrating possible mild colonic wall thickening which would be attributed to colitis. No bowel obstruction.

 

Assessment:

28 y/o female with no PMH presented to ED with 4 days of fever, chills, headache, loss of taste, nausea, vomiting and diarrhea. Patient endorsed regular cannabis use, denied sick contacts and recent travel. Labs significant for lactate of 1.9, WBC count of 3.16 and lymphocyte count of 40.2. CXR and CT Abdomen/pelvis negative. Patient admitted to medicine for covid and cyclic vomiting.

 

Plan:

Covid-19

• O2 sat 100% on RA, no supplemental O2 needed
• CXR negative
• VTE mechanical ppx with sequential compression device

 

Vomiting, nausea, diarrhea 2/2 viral gastroenteritis vs. Covid-19

• Ondansetron 4 mg IV daily
• Normal Saline 1 L
• Metoclopramide 10 mg IV
• Blood cx, C.diff PCR, GI PCR panel
• Clear liquid diet

 

Follow-up:

• lactate decreased to 1.2, WBC increased to 4.5, lymphocytes decreased to 36
• GI PCR panel/C.diff PCR/blood cx negative, nausea and vomiting attributed to Covid-19 and cannabis use
• Patient discharged upon successful solid food challenge/resolution of sx with PRN Ondansetron