Age: 77.0
Sex: F
Vaccine: COVID19
Symptoms: Hypertension, Ovarian cyst, Small intestinal obstruction, Type 2 diabetes mellitus
Clinical narrative: Date of Admission: 9/9/2023   Date of Discharge: 9/12/2023     Issues to be Addressed at Follow-up: R ovarian cyst   Pending Study Results at Discharge:  Unresulted Lab Orders    No orders found from 8/13/2023 to 9/13/2023.       Final Diagnoses:  Active Hospital Problems   Diagnosis   ? (Principal) PARTIAL SMALL BOWEL OBSTRUCTION   ? COVID-19 DISEASE   ? HTN (HYPERTENSION)       9/6/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.    BP Readings from Last 3 Encounters: 06/19/23 136/66 06/02/23 140/68 05/19/23 156/67   ROS neg   Plan Increase verapamil to 120 mg bid ( 5/19/23)  Monitor closely at home Advised patient to email/call if any worsening/recurrence of sympts noted.       ? DM 2   ? HYPERLIPIDEMIA       5/19/2023 - Established diagnosis. Briefly reviewed plan today. Continue current regimen.           Resolved Hospital Problems No resolved problems to display.     Discharge Disposition:  Home   Medications, instructions, follow up information: See patient Discharge Instructions/AVS.   Hospital Course and Significant Findings:   Operations & Procedures: ? None   Summary / Hospital Course: Patient is a/an 80 Y old female history of c-section, HTN, DM, difficulty holding urine/stool recently, started on anti-diarrheals and has been constipated for last 2 days. Underwent CT A/P with suggestion of partial small bowel obstruction of proximal small bowel and distended stomach and incidental right adnexal cystic lesion of 7cm. NG tube placed and GGP was initiated.  On 9/11, a clamp trial was performed which she tolerated well.  She had return of bowel function.  The NG tube was removed and she was started on clears.  She tolerated this well and was advanced to regular.  She was restarted on her home medications.  CA 19-9 and CA125 were checked and were normal.  She was discharged home with instructions to follow-up with her PCP regarding the right ovarian mass.  Patient was instructed to start Metamucil daily and add MiraLAX as needed for constipation.   Primary Procedures:  None   Secondary Procedures: None   Reason for Hospital Admission (Admitting Diagnosis):  SBO   Complications: none   Consults:  HOSPITAL MEDICINE - ONGOING INPATIENT CONSULTATION. Smoker: No.   Condition on Discharge: stable   Code Status at Time of Discharge: Full Code     Note Details  Author (M.D.) File Time 9/12/2023  3:08 PM Author Type Physician Status Addendum Last Editor (M.D.) Specialty TRAUMA SURGERY Hospital Acct # Admit Date 9/9/2023  ED to Hosp-Admission (Discharged) on 9/9/2023  ED to Hosp-Admission (Discharged) on 9/9/2023   Revision History   Detailed Report  Note shared with patient Additional Orders and Documentation   Results Imaging   Meds    Orders    Flowsheets   Encounter Info:  History, Allergies, Education, Care Plan, Detailed Report   Hospital Problem List   HYPERLIPIDEMIA  DM 2  HTN (HYPERTENSION)  PARTIAL SMALL BOWEL OBSTRUCTION  COVID-19 DISEASE Care Timeline  09/09   Admitted from ED (Observation)  09/12   Discharged 2130  Discharge   Home or Self Care.   Discharge Instructions (AVS) (Printed 9/12/2023) Medication List at Discharge   atorvastatin calcium 10 mg Oral DAILY, to prevent heart attacks and strokes  blood sugar diagnostic 1 Strip Miscell. (Med.Supl.;Non-Drugs) EVERY MORNING, to measure blood sugar  lancets 30 gauge 1 Each Miscell. (Med.Supl.;Non-Drugs) EVERY MORNING, to measure blood sugar  metformin HCl 500 mg Oral EVERY EVENING WITH A MEAL  trospium chloride 20 mg Oral EVERY BEDTIME  verapamil HCl 120 mg Oral 2 TIMES A DAY