Age: 65.0
Sex: F
Vaccine: PPV
Symptoms: Abdominal pain upper, Acute kidney injury, Alanine aminotransferase normal, Anion gap, Aspartate aminotransferase normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on September 30, 2022 01:33 EDT   Verified By: MD on September 30, 2022 01:33 EDT   Encounter Info: Inpatient, 09/30/22 - 10/02/22   * Final Report *  Chief Complaint   Abd pain  History of Present Illness/Subjective   Patient is a 67 year old woman who presents to the ER w/ abd pain. Patient states that her pain is located in the LUQ. The pain started earlier this evening and is associated w/ vomiting. Pain radiates into her back. She denies any fever, chills, night sweats. Upon arrival to the ER vitals were notable for a HR of 124. Labs showed a Hgb of 15.7. Cr was 1.24. CT abd/pelvis revealed an SBO. NGT was placed and doctor was consulted in the ER. Patient was given fluids and pain meds 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   Constitutional:  No acute distress,  well-nourished Eyes:  no scleral icterus ENMT:  Moist oral mucosa Respiratory:  Breathing comfortably on room air Cardiovascular:  Regular rate and rhythm Gastrointestinal:  non-distended Musculoskeletal:  intact ROM Integumentary:  no rashes Neurologic: no focal deficits Psychiatric:  Cooperative, appropriate mood and affect    Assessment/Plan   Patient is a 67 year old woman admitted w/ an SBO.    1. SBO (small bowel obstruction)    -NPO  -NG on LIS  -Doctor consulted  -LR at 100cc/hr  2. AKI (acute kidney injury)    -Likely pre-renal in nature  -PVR urine to r/o obstruction  -Renally dose meds  -Avoid nephrotoxins  -LR at 100cc/hr  3. Lymphadenopathy   -Given h/o lymphoma will need to consult Heme/Onc in the AM  4. GERD (gastroesophageal reflux disease)   -Continue PPI     Code Status   Resuscitation Status - Ordered    -- 09/30/22 1:30:00 EDT, Full Code   Chronic Problem List    Encounter for long-term (current) use of medications  GERD (gastroesophageal reflux disease)  History of 2019 novel coronavirus disease (COVID-19)  Invasive ductal carcinoma of right breast  Irritable bowel syndrome with predominant constipation  Mantle cell lymphoma  Prediabetes  Right kidney mass  Routine health maintenance  Procedure/Surgical History  ?Excision lymph node Right groin (03/18/2021) ?Hemorrhoidectomy (11/11/2020) ?Colonoscopy (11/09/2020) ?Eye examination (03/28/2019) ?colonoscopy (1988) ?Cystocele ?FH: TAH-BSO (total abdominal hysterectomy and bilateral salpingo-oophorectomy) ?Left ankle ?right ankle ?Right shoulder ?Total hysterectomy  Surgical History Internal  07/21/2021    Mastectomy Partial     03/18/2021    Lymph Node Excision Biopsy      11/11/2020    Hemorrhoidectomy     11/09/2020    Colonscpy Diagnostic/Screen     Medications   Home Medications (5) Active  Anusol-HC 2.5% topical cream See Instructions, Rectally BID  Carafate 1 g oral tablet 1 GM = 1 Tablet, Orally, 4 Times Daily  dicyclomine 10 mg oral capsule 10 mg = 1 Capsule, Orally, TID, Take 30 minutes before meals.  Digestive Advantage Daily Probiotic oral capsule 2 capsules, Orally, QAM  Flonase 50 mCg/inh nasal spray 50 mCg = 1 Spray, Nostrils, Both, Daily  Active Scheduled Inpatient Medications  enoxaparin, Injection, 40 mg, Subcutaneous, Q24H, Start: 09/30/22 02:00:00  Lactated Ringers  1,000 mL IV  100 mL/hr       One-Time Medications Given 09/29/22 00:00:00 TO 09/30/22 01:31:14  None Reported  PRN Medications (0600 - 0559) from 09/29 - 09/30  morphine, 2 mg, IV Push, Q4H, 0  Dose(s)   Allergies   Ceftin (Unknown)  Social History   Alcohol  Denies  Electronic Cigarette/Vaping  E-Cigarette Use Never.  Employment/School  Employed, Retired, Work/School description: RETIRED then went back to work part time   Exercise  Exercise type: Walking.  Home/Environment  widowed/ 3 children  Nutrition/Health  Type of diet: no gluten dairy or sugars low carbs. Caffeine intake amount: coffee morning 1 cup.  Other  Substance Abuse  Denies  Tobacco  Tobacco Use: Never (less than 100 in lifetime).  Family History   Cancer of colon: Grandmother.  Cancer of ovary: Grandmother.  Hypertension: Mother.  Father: History is unknown  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 12.3 k/cumm High (09/29/22 22:19:00)  RBC: 5.41 million/cumm High (09/29/22 22:19:00)  Hgb: 15.7 GM/dL High (09/29/22 22:19:00)  Hct: 47.6 % (09/29/22 22:19:00)  MCV: 88 fL (09/29/22 22:19:00)  MCH: 28.9 pg (09/29/22 22:19:00)  MCHC: 32.9 GM/dL (09/29/22 22:19:00)  RDW: 13.2 % (09/29/22 22:19:00)  Platelet: 360 k/cumm (09/29/22 22:19:00)  MPV: 8.7 fL (09/29/22 22:19:00)  Neutrophils %: 70 % (09/29/22 22:19:00)  Lymphocytes %: 19 % (09/29/22 22:19:00)  Monocytes %: 9 % (09/29/22 22:19:00)  Eosinophils %: 1 % (09/29/22 22:19:00)  Basophils %: 1 % (09/29/22 22:19:00)  Absolute Neutrophil: 8.6 k/cumm High (09/29/22 22:19:00)  Absolute Lymphocyte: 2.3 k/cumm (09/29/22 22:19:00)  Absolute Monocyte: 1.1 k/cumm (09/29/22 22:19:00)  Absolute Eosinophil: 0.1 k/cumm (09/29/22 22:19:00)  Absolute Basophil: 0.1 k/cumm (09/29/22 22:19:00)  Chemistry:  Sodium SerPl QN: 141 mmol/L (09/29/22 22:19:00)  Potassium SerPl QN: 3.7 mmol/L (09/29/22 22:19:00)  Chloride SerPl QN: 99 mmol/L (09/29/22 22:19:00)  Carbon Dioxide SerPl QN: 25 mmol/L (09/29/22 22:19:00)  Anion Gap: 17 mmol/L High (09/29/22 22:19:00)  BUN SerPl QN: 13 mg/dL (09/29/22 22:19:00)  Creatinine SerPl QN: 1.24 mg/dL High (09/29/22 22:19:00)  Estimated GFR (CKD-EPI): 45 mL/min/1.73m2 Low (09/29/22 22:19:00)  Estimated GFR (CKD-EPI, no race): 48 mL/min/1.73m2 Low (09/29/22 22:19:00)  Estimated CRCL (CG): 49 mL/min Low (09/29/22 22:19:00)  Glucose SerPl QN: 128 mg/dL High (09/29/22 22:19:00)  Calcium Total SerPl QN: 11.8 mg/dL High (09/29/22 22:19:00)  Alkaline Phos SerPl QN: 77 Units/L (09/29/22 22:19:00)  ALT SerPl QN: 23 Units/L (09/29/22 22:19:00)  AST SerPl QN: 20 Units/L (09/29/22 22:19:00)  Bilirubin Direct SerPl QN: 0.1 mg/dL (09/29/22 22:19:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (09/29/22 22:19:00)  Total Protein SerPl QN: 8.8 GM/dL High (09/29/22 22:19:00)  Albumin SerPl QN: 5.3 GM/dL High (09/29/22 22:19:00)  Magnesium SerPl QN: 2.3 mg/dL (09/29/22 22:19:00)  Lipase SerPl QN: 66 Units/L High (09/29/22 22:19:00)  Diagnostics  Radiology Results - Last 24 hours Across Visits 09/29/2022 22:58 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  Moderate grade small bowel obstruction with graded narrowing inthe mid abdomen (transition point on series 4, image 51), withcollapse of the distal bowel to the level of the ileum.2.  Enlarging right inguinal lymph nodes in the setting of priorlymphoma should be evaluated for recurrence.Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discussthis case further can contact the Abdominal Imaging Reading Room. For after-hours or emergency department cases, pleasecall.    09/30/2022 01:00 - XR Chest PA or AP Portable  IMPRESSION: 1.  Gastric suction tube with tip in sidehole in the stomach. The tipis directed cephalad at the left hemidiaphragm.2.  The lungs are clear. Thank you for consulting our team of subspecialty radiologists. Healthcare providers wishing to discussthis case further can contact the Cardiothoracic Reading Room. For after-hours or emergency department cases, pleasecall.             Signature Line Electronically Signed on 09/30/22 01:33 EDT ________________________________________________________