Huntsville Hospital System

Helen Keller Hospital

101 Sivley Road
Huntsville, Alabama 35801

Patient: BURGESS, ALLYSON BRIANNE

MRN: 10383797 Admit Date/Time: 2/28/2024 11:13 CST
Financial Number: 10383797-0001 Disch Date/Time:
DOB/Age/Gender: 9/28/1989 34 years Female Attending: Karr,DO,Aaron W
Location: 2C-HK; K255; P Referring: Karr,DO,Aaron W
Deceased Date/Time: PCP: Karr,DO,Aaron W

History and Physical Reports

Document Type: History and Physical
Service Date/Time: 2/28/2024 13:04 CST
Result Status: Auth (Verified)
Document Subject: Admission H & P
Sign Information: Oliver,CRNP,Abbey (2/28/2024 13:25 CST)

Chief Complaint Problem List/Past Medical History

n/v in pregnancy Ongoing
history of Polysubstance abuse
History of Present Illness
Thrombocytosis
patient was seen earlier today in the Shoals primary care office with Historical
complaints of nausea, vomiting, dehydration, and fatigue. She was No qualifying data
directly admitted from SPC for hyperemesis gravidarum, dehydration, at
Procedure/Surgical History
16 weeks of pregnancy. She has a history of polysubstance abuse and
• thyroid surgery
thrombocytosis.
• umbilical hernia
Vitals & Measurements
Review of Systems T: 36.3 °C (Temporal Artery)
GENERAL/CONSTITUTIONAL: 16 weeks pregnant HR: 80(Peripheral) BP: 140/93
CARDIOVASCULAR: Per HPI, but otherwise no pain, shortness of breath, syncope or SpO2: 100% HT: 177 cm WT: 67.5 kg
presyncope.
RESPIRATORY: Denies shortness of breath, wheezing, stridor, or cough. Medications
GASTROINTESTINAL: + nausea, vomiting Inpatient
NEUROLOGIC: Denies stroke, seizure, or paresthesias. 0.9% NaCl bolus, 1000 mL, IV Bolus, Once
PSYCHIATRIC: Denies depression, psychosis, or suicidal ideation. 0.9% NaCl drip 1,000 mL, 1000 mL, IV
Phenergan, 25 mg= 1 tab, Oral, q 4 hr, PRN
Physical Exam Prenatal Multivitamins, 1 EA, Oral, Daily
CONSTITUTIONAL: General Appearance: A well-developed female in no acute distress, Synthroid, 175 mcg= 1 tab, Oral, Daily
resting comfortably. traZODone, 50 mg= 1 tab, Oral, q HS
RESPIRATORY: Clear to auscultation bilaterally. No increased work of breathing. Home
CARDIOVASCULAR: Regular rate and rhythm. No murmur, rub, or gallop. S1 and S2 Synthroid, 175 mcg, Oral, Daily
audible heart sounds with no S3. Carotid and pedal pulses are normal bilaterally. traZODone 100 mg oral tablet, 200 mg,
GI (ABDOMEN): Soft, nontender, nondistended, no masses. No hepatosplenomegaly. No Oral, Daily, PRN
hernia.
MUSCULOSKELETAL: Normal range of motion throughout. No cyanosis, clubbing, or Allergies
ischemia. Normal muscle strength throughout. Levaquin (Unknown)
PSYCH: Alert and oriented to time, place, and person. Mood and affect are appropriate. Stadol (Unknown)
Assessment/Plan Social History
1. Hyperemesis gravidarum doesnt use tobacco or alcohol. hx drug abuse.
-0.9% normal saline 1 L bolus over 2 hours and then 100 cc/hour. Quit doing heroin 2 months ago when she
-Regular diet. found out she was pregnant.
-UDS, alcohol level, urinalysis, CBC with differential and CMP now and in Family History
the morning, check quantitative hCG level none
-consult Dr. Snyder Lab Results

_______________________________________________________________________________________________
Report Request ID: 66621192 Page 1 of 3 Print Date/Time: 2/28/2024 21:03 CST
 Huntsville Hospital System
Helen Keller Hospital

Patient Name: BURGESS, ALLYSON BRIANNE

MRN: 10383797 Admit Date/Time: 2/28/2024 11:13 CST
Financial Number: 10383797-0001 Disch Date/Time:
DOB/Age/Gender: 9/28/1989 34 years Female Attending: Karr,DO,Aaron W
Referring: Karr,DO,Aaron W
PCP: Karr,DO,Aaron W

History and Physical Reports

-SCDs for DVT prophylaxis 24 hours Labs

2. Dehydration Routine
Chemistry
3. Second trimester pregnancy
abdominal /uterine ultrasound Event Event Normal Date/Time
Name Result Range
4. Thrombocytosis
Alcohol, <10 02/28/24
consult heme/onc
Ethyl 12:04:00

Hematology
Event Event Normal Date/Time
Name Result Range
WBC Count 10.14 02/28/24
x10^3/mcL 12:04:00
RBC Count 4.05 02/28/24
x10^6/mcL 12:04:00
Hemoglobin 12.8 g/dL 02/28/24
12:04:00
Hematocrit 36.8 % 02/28/24
12:04:00
MCV 90.9 fL 02/28/24
12:04:00
MCH 31.6 pg 02/28/24
12:04:00
MCHC 34.8 g/dL 02/28/24
12:04:00
RDW 15.5 % 02/28/24
12:04:00
PLATELET 962 02/28/24
COUNT x10^3/mcL 12:04:00
MPV 8.4 fL 02/28/24
12:04:00
Abs 7.81 02/28/24
Neutrophils x10^3/mcL 12:04:00
Abs 1.62 02/28/24
Lymphocyte x10^3/mcL 12:04:00
s
Abs 0.59 02/28/24
Monocytes x10^3/mcL 12:04:00
Abs 0.01 02/28/24
Eosinophils x10^3/mcL 12:04:00
Abs 0.05 02/28/24
Basophils x10^3/mcL 12:04:00
Neutrophil 77 % 02/28/24
12:04:00
Lymphocyte 16 % 02/28/24
12:04:00
Monocyte 5.8 % 02/28/24
12:04:00
Eosinophil 0.1 % 02/28/24
12:04:00

_________________________________________________________________________________________________
Report Request ID: 66621192 Page 2 of 3 Print Date/Time: 2/28/2024 21:03 CST
 Huntsville Hospital System
Helen Keller Hospital

Patient Name: BURGESS, ALLYSON BRIANNE

MRN: 10383797 Admit Date/Time: 2/28/2024 11:13 CST
Financial Number: 10383797-0001 Disch Date/Time:
DOB/Age/Gender: 9/28/1989 34 years Female Attending: Karr,DO,Aaron W
Referring: Karr,DO,Aaron W
PCP: Karr,DO,Aaron W

History and Physical Reports

Basophil 0.5 % 02/28/24
12:04:00
Immature 0.6 % 02/28/24
Granulocyte 12:04:00
s
Nucleated 0 02/28/24
RBC /100(WBCs) 12:04:00
Absolute 0.06 02/28/24
Immature x10^3/mcL 12:04:00
Granulocyte
s
Diff Type AUTOMATE 02/28/24
D 12:04:00

Electronically Signed on 02/28/24 01:25 PM

________________________________________________________
Oliver, CRNP, Abbey

_________________________________________________
Karr, DO, Aaron W

_________________________________________________________________________________________________
Report Request ID: 66621192 Page 3 of 3 Print Date/Time: 2/28/2024 21:03 CST