Age: 57.0
Sex: M
Vaccine: COVID19
Symptoms: Alcohol abuse, Anion gap, Anticoagulant therapy, Arteriosclerosis, Ascites
Clinical narrative: Date of Service- Aug-01-2022 06:48. Chief Complaint: pain. HPI / Subjective: Patient is a 58 year old male who was transferred to our facility from alternate Hospital due to a suspected small bowel obstruction. On presentation he was found to be COVID-19 positive. His past medical history is significant for hypertension, methamphetamine use, and tobacco abuse. The internal medicine team was consulted in the care of this patient for his continued abdominal complaints despite treatment complicated by his COVID-19 positive status. He is on hospital day 7. Yesterday afternoon the patient attempted to consume a full liquid diet but did not tolerate this. He had significant abdominal pain overnight requiring Dilaudid. This morning the patient is seen resting in his hospital bed. He is having a lot of abdominal cramping and discomfort. The pain is primarily in the lower quadrants of the abdomen. Any pressure in the lower quadrants makes the pain worse. The Dilaudid helps the most. He was able to sleep overnight with the pain medication. No stool has been passed recently. Some gas has passed but is minimal. He did not have any episodes of emesis. REVIEW OF SYSTEMS Constitutional: Patient denies fevers and chills. Cardiovascular: Patient denies palpitations, chest pain, and lower extremity edema. Respiratory: Patient denies dyspnea, cough, and sputum production. Gastrointestinal: Patient denies nausea, vomiting, constipation, diarrhea. Reports abdominal pain. Genitourinary: Patient denies dysuria or hematuria. Neurologic: Patient denies headache or dizziness. Objective: Vital Signs- Aug-01-2022 06:46 T 97.8 HR  53 RR 16 BP 160  / 86 O2 Sat 100 Aug-01-2022 0430 T 97.9 HR  58 RR 16 BP 136 / 89 O2 Sat 99 Intake and Output: previous day current day: encounter cumulative: Intake 550 ? 15208 Output 5 ? 808 Diff (I-O) 545 ? 14400 PHYSICAL EXAM: Constitutional: Patient appears older than stated age, acutely and chronically ill, and is in no acute distress at this time. Cardiovascular: Regular rate and rhythm without murmur, gallop, or rub. No edema present in the lower extremities. Radial pulses intact 2+ bilaterally. Respiratory: Lungs clear to auscultation bilaterally, no wheezing, no rhonchi, no rales. No accessory muscle use, no respiratory distress. Patient is currently on room air. Gastrointestinal: The patient refused an abdominal examination this morning. Abdomen appears distended. Psychiatric: Patient responds appropriately to questions and displays flat affect. His responses are short. Appears to have good judgment. Lab Results: Aug-01-2022 05:05 Chemistry: GLUCOSE  124BUN  30CREAT  0.8MDRD GFR  99NA  132K  4.5CL  100CALCIUM  7.4ALK PHOS  79CO2  22.9AST  73ALT  66AST/ALT  1.1TL PROT  6.3ALBUMIN  2.0TBILI  1.3DBILI  0.4OSMO  272.1ANION GP  13.6BUN/CRE  37.5 Aug-01-2022 05:05 Hematology WBC  17.1RBC  4.79HGB  14.3HCT  41.3MCV  86.2MCH  29.9MCHC  34.6RDW  17.0RDWSD  50.3PLT  75MPV  10.4AUTONEU%  78.2AUTOLYM%  10.0AUTOMON%  8.0AUTOEOS%  1.5AUTOBAS%  0.2AUTONEU#  13.4AUTOLYM#  1.7AUTOMON#  1.4AUTOBAS#  0.0AUTOEOS#  0.3NRBC%  0.0NRBC  0.0HGB/HCT  2.9IG#  0.35IG%  2.1 Procedure(s) Performed: None Active Medications: GUAIFENESIN ER 600 MG ORALLY BIDPRN for COUGH BENZONATATE 100 MG ORALLY Q8HPRN for COUGH FUROSEMIDE 20 MG ORALLY DAILY SPIRONOLACTONE 50 MG ORALLY DAILY cefTRIAXone INJ 2000 MG IV Q24HI 200 ML/HR SODIUM CHLORIDE 0.9% MINIBAG+ 100 ML PLEASE ENTER INDICATION IN COMMENTS: possible peritonitis **do not run with lactated ringers, flus h line before and after administration** GABApentin 600 MG ORALLY BEDTIME DEXAMETHASONE INJ 4 MG/ML 6 MG IV PUSH DAILY PROPRANOLOL HCL 10 MG ORALLY TID hold for HR <60 or SBP <105 LABETALOL HCl INJ 20 MG / 4 ML 10 MG IVP Q1HPRN for ELEVATED BLOOD PRESSURE For systolic blood pressure >160 and heart rate >60. Notify physician if 3 does are used in 3 hours. (Suspend) ENOXAPARIN INJ 40 MG / 0.4 ML 40 MG SUBCUT DAILY for creatinine clearance greater than or equal to 30 milliliters / minute amLODIPine BESYLATE 2.5 MG ORALLY QDBP ***note dose** *** 1/2 tablet *** ASPIRIN EC 325 MG ORALLY DAILY traMADoL HCL 50 MG ORALLY Q6HPRN for SEVERE PAIN (7-10 ON PS) Use first, before Dilaudid DOCUSATE SODIUM 100 MG ORALLY BID LORATADINE 10 MG ORALLY DAILY FAMOTIDINE MAXIMUM STRENGTH 20 MG ORALLY BID HYDROmorphone HCL 0.5 MG/0.5ML 0.5 MG IV PUSH Q2HPRN for SEVERE PAIN (7-10 ON PS) For breakthrough pain only. PROMETHAZINE HCL INJ 25 MG/ 1 ML 12 MG IVPB Q6HPRN 200 ML/HR for NAUSEA/VOMITING SODIUM CHLORIDE 0.9% MINIBAG+ 50 ML infuse over 15 minutes Give SECOND. Give only if first choice is ineffective. ONDANSETRON HCl INJ 4 MG / 2 ML 4 MG IVPUSH Q8HPRN for NAUSEA/VOMITING Give FIRST: ACETAMINOPHEN 650 MG ORALLY Q4HPRN for FEVER OR MILD PAIN 1-3 ON PS max 4,000 milligrams acetaminophen per 24 hours Plan Assessments: - Severe sepsis due to spontaneous bacterial peritonitis, improving - Possible underlying enteritis due to COVID-19 infection vs transient bowel ischemia secondary to     methamphetamine use vs bowel wall edema from 3rd spacing leading to SBP - COVID-19 infection without hypoxia - Abdominal pain with Constipation, possible ileus - Hepatitis C, not previously treated - Essential hypertension unknown control - Normocytic anemia, uncertain chronicity - Moderate ascites seen on CT July 2022 - Splenomegaly seen on CT July 2022 - Esophageal varices seen on CT July 2022 - Suspected chronic liver disease  - Coronary artery disease - Right sided pleural effusion - Hyperbilirubinemia, Indirect - Osteoarthritis - Elevated transaminases, improving - Thrombocytopenia, improving - Abdominal atherosclerosis seen on CT July 2022 - Cirrhosis of the liver seen on CT July 2022 with nodules appreciated, malignancy vs regeneration secondary to     alcohol abuse vs hepatitis c - Cholelithiasis seen on CT July 2022 - Nephrolithiasis seen on CT July 2022 - Gynecomastia seen on CT July 2022 - Mild protein calorie malnutrition - Marijuana use - Methamphetamine use - Chronic tobacco abuse - History of alcohol use disorder, sober for 3 years Recommendations:     As the patient has been somewhat bradycardic, I will hold the propranolol at this time as this will worsen his heart rate. The spironolactone and Lasix have been held which should help the hyponatremia. The patient appears dry this morning which would be worsened by the diuretics as well. He will need to be started on a regimen for ascites once his oral intake improves and he can tolerate it. I discussed the patient's viral RNA load with him. He will need close follow up outpatient and treatment for his hepatitis C. We discussed that without treatment he will have the risk of developing hepatic failure and hepatocellular carcinoma. We will continue to trend his inflammatory markers. The internal medicine team would like to thank Dr. for including us in the care of his patient. We will be forthcoming with further recommendations as they arise. Electronically signed by DO DO on Aug-01-2022 09:24.