Age: 55.0
Sex: M
Vaccine: COVID19-2
Symptoms: Abdominal infection, Abdominal pain, Abdominal tenderness, Alanine aminotransferase normal, Anion gap
Clinical narrative: Document Type: ED Physician Progress Note   Document Subject: ED Progress Note   Performed By: MD on November 20, 2022 05:00   Verified By: MD on November 20, 2022 06:02   Encounter Info: Hospital, Inpatient, 11/20/22 -     * Final Report *        Basic Information  Time Seen: MD / 11/20/2022 03:53  Chief Complaint  Vomiting  History of Present Illness     The patient is a 56 y/o male who presents to the ED with right-sided abdominal pain that began at 2330 last night. At 2200 he had a coffee, which he attributes to causing his pain. He has vomited 4x since 2330. He denies hematemesis. He states that his pain is a sharp 9.5/10 and feels like when he had gallbladder problems in the past, but worse. He is unable to get comfortable. He denies diarrhea.  Review of Systems     Constitutional:  no fever, no chills, no sweats, no weakness, no fatigue Eyes:  no recent vision problems, no discharge, no blurred vision Ears, Nose, Mouth, Throat:  no ear pain, no throat pain Respiratory:  no SOB, no cough, no wheezing Cardiovascular:  no chest pain, no palpitations, no diaphoresis Gastrointestinal:  + abdominal pain, + nausea, + vomiting, no diarrhea, no constipation Genitourinary:  no dysuria, no bleeding, no discharge Musculoskeletal:  no back pain, no muscle pain, no joint pain Skin:  no rash Neurologic:  no headache, no dizziness, no numbness Psych: no anxiety, no depression Endocrine:  negative except HPI Heme/Lymph: negative except HPI Allergy/Immunologic: negative except HPI General:  All other systems reviewed and otherwise negative  Physical Exam/Objective  Vitals & Measurements last 24 hours  VITAL SIGNS  Temp C:       35.9 DegC  Heart Rate:       69 bpm  Resp Rate:       26 br/min  BP:       160 / 91 mmHg  SpO2 (%):       99 %  O2 Device:       Room air     Height CM: 182.8 cm  Weight KG: 109.7 kg  Ideal Body Weight: 77.53 kg     General: alert, significant distress 2/2 pain, unable to sit still Skin: warm, dry, no pallor, no rash Head: normocephalic Eye: PERRL, EOMI, normal conjunctiva ENMT: oral mucosa moist, no pharyngeal erythema or exudate Neck: supple Cardiovascular: RRR, no murmur, no edema Respiratory: Lungs CTA, non-labored respirations, BS equal Chest wall: nontender, no deformity GI: soft, RUQ ttp, nondistended, no organomegaly GU: N/A Rectal: N/A Back: nontender, normal ROM Musculoskeletal: normal ROM, normal strength, no tenderness, no swelling Neuro: AOx4, no focal neuro deficits, CN II-XII intact, normal sensory, normal motor, normal speech Psych: Cooperative, appropriate mood and affect  Medical Decision Making     DDx includes but is not limited to: gastroenteritis, IBS flare, appendicitis, diverticulitis, UTI, colitis, SBO, cholelithiasis, cholecystitis, pancreatitis, hepatitis, GERD, PUD, AAA, renal colic, other abdominal pain   Routine abdominal labs and CT a/p ordered.  Morphine and zofran ordered for Sx relief.  Droperidol ordered.  Lactate@ 5.1, will start sepsis orderset and get IVFs and ABx.   CT shows no acute findings. EKG   Date: 11/20/22  Time: 0513  Rate/Rhythm: 57 bpm, Sinus bradycardia w/ sinus arrythmia  Axis: WNL  Intervals: WNL   ED Interpretation: No significant change from prior tracing on 6/13/22             Re-Assessment  11/20/22 05:01:20 Pain is now 5/10.  11/20/22 06:02:10 Patient care transitioned to Dr.   Condition     Condition: Improved, Stable Disposition: Transition     Time:  11/20/22 06:01:46   to   Admitting physician: Dr.  Counseled: Patient , Regarding diagnosis, Regarding diagnostic results, Regarding treatment plan, Regarding prescription,  Patient   indicated understanding of instructions.  Assessment/Plan       1. Right sided abdominal pain   R10.9    Orders:   piperacillin-tazobactam, 3.375 GM, IVPB, Injection, ONCE, Indication: Intra-Abdominal Infection, 11/20/22 9:00:00, 11/20/22 9:00:00, Total Volume (mL) = 50  vancomycin, 2 GM, IVPB, Injection, ONCE, Indication: Intra-Abdominal Infection, STAT, 11/20/22 4:41:00, 11/20/22 4:41:00, 250 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 500  Auto Diff  Basic Metabolic Panel  Blood CX  Blood CX  CBC w/Differential  CT Abd/Pelvis W/IV Contrast  Hepatic Function Pnl  Lactate Pl Venous QN  Lactate Pl Venous QN  Lipase SerPl QN  Magnesium SerPl QN  Sepsis Tracking  Troponin-I High Sensitivity  Urinalysis w Culture Rflx     Follow Up  No qualifying data available   Chronic Problem List    Cervicalgia  Hypertension  Metatarsalgia of both feet  Mixed dyslipidemia  Plantar fasciitis, bilateral  Tinnitus  Urinary urgency  Valgus deformity of both feet      Medications  Home Medications (2) Active atorvastatin 40 mg oral tablet 1 Tablet, Orally, At Bedtime, Must keep appointemtn for further refills. tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, QHS  Medication Administration   Given  droperidol, 1.25 mg, IV Push  Lactated Ringers - ED Bolus, 3291 mL, IVPB  morphine inj ED, 4 mg, IV Push  ondansetron, 4 mg, IV Push  piperacillin-tazobactam, 4.5 GM, IV Push. For: Intra-Abdominal Infection  Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Hobbies/Interests   Music Instruments Creative:. Video Games, computer art, web design Science Technology.   Nutrition/Health   Diet: Regular.   Substance Abuse   Current, Marijuana, Daily   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   Patient was adopted  Family history is unknown  Lab Results       Hemogram-Platelets-WBC Differential FS  LATEST RESULTS  HISTORICAL RESULTS          WBC  11/20/22 04:01  19.0  High  06/13/22  9.5          RBC  11/20/22 04:01  4.74  06/13/22  4.81          Hgb  11/20/22 04:01  14.4  06/13/22  14.9          Hct  11/20/22 04:01  43.3  06/13/22  43.7          MCV  11/20/22 04:01  91  06/13/22  91          MCH  11/20/22 04:01  30.3  06/13/22  30.9          MCHC  11/20/22 04:01  33.2  06/13/22  34.0          RDW  11/20/22 04:01  13.7  06/13/22  13.4          Platelet  11/20/22 04:01  323  06/13/22  276          MPV  11/20/22 04:01  8.0  06/13/22  8.2          Neutrophils %  11/20/22 04:01  83  06/13/22  77          Lymphocytes %  11/20/22 04:01  12  06/13/22  16          Monocytes %  11/20/22 04:01  5  06/13/22  6          Eosinophils %  11/20/22 04:01  0  06/13/22  1          Basophils %  11/20/22 04:01  0  06/13/22  0          Absolute Neutrophil  11/20/22 04:01  15.8  High  06/13/22  7.3          Absolute Lymphocyte  11/20/22 04:01  2.2  06/13/22  1.5          Absolute Monocyte  11/20/22 04:01  0.9  06/13/22  0.6          Absolute Eosinophil  11/20/22 04:01  0.1  06/13/22  0.1          Absolute Basophil  11/20/22 04:01  0.1  06/13/22  0.0           Routine Chemistry Tests FS  LATEST RESULTS  HISTORICAL RESULTS          Sodium SerPl QN  11/20/22 04:01  133  Low  06/13/22  139          Potassium SerPl QN  11/20/22 04:01  4.9  06/13/22  4.3          Chloride SerPl QN  11/20/22 04:01  100  06/13/22  108          Carbon Dioxide SerPl QN  11/20/22 04:01  18  Low  06/13/22  24          Anion Gap  11/20/22 04:01  15  High  06/13/22  7          BUN SerPl QN  11/20/22 04:01  15  06/13/22  14          Creatinine SerPl QN  11/20/22 04:01  1.13  06/13/22  1.01          Estimated GFR (CKD-EPI, no race)  11/20/22 04:01  76  06/13/22  87          Estimated CRCL (CG)  11/20/22 04:01  93  06/13/22  107          Glucose SerPl QN  11/20/22 04:01  186  High  06/13/22  125  High          Calcium Total SerPl QN  11/20/22 04:01  9.7  06/13/22  9.3          Alkaline Phos SerPl QN  11/20/22 04:01  71  06/13/22  80          ALT SerPl QN  11/20/22 04:01  20  06/13/22  17          AST SerPl QN  11/20/22 04:01  27  06/13/22  14          Bilirubin Direct SerPl QN  11/20/22 04:01  0.1              Bilirubin Total SerPl QN  11/20/22 04:01  0.5  06/13/22  0.6          Total Protein SerPl QN  11/20/22 04:01  7.6  06/13/22  7.3          Albumin SerPl QN  11/20/22 04:01  4.4  06/13/22  4.4          Magnesium SerPl QN  11/20/22 04:01  1.8              Lipase SerPl QN  11/20/22 04:01  18              Lactate Venous Pl QN  11/20/22 04:01  5.1  High          Diagnostic Results  CT Abd/Pelvis W/IV Contrast    11/20/22 05:00:50  IMPRESSION:  1. No acute findings in the abdomen or pelvis.  2. Cholelithiasis without findings of acute cholecystitis     Thank you for consulting our team of subspecialty radiologists at   Radiology. Healthcare providers wishing to discuss  this case further can contact the Abdominal Imaging Reading Room.  For after-hours or emergency department cases, please  call.   Electronically Signed by:     Signed By: MD        Signature Line Electronically Signed on 11/20/22 06:02  ________________________________________________________ MD