Age: 81.0
Sex: F
Vaccine: FLU3
Symptoms: Anion gap, Aspartate aminotransferase normal, Bilirubin conjugated increased, Blood albumin normal, Blood alkaline phosphatase normal
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on October 22, 2024 16:00    Verified By: MD on October 22, 2024 16:00   Encounter Info: Hospital, Inpatient, 10/22/24 -     * Final Report *          History of Present Illness/Subjective     Patient is an 81-year-old female with past history significant for hypertension, hypothyroidism and hyperlipidemia present emergency room with acute onset of lower quadrant abdominal pain.  Patient states that she for the most part is very healthy.  On Sunday morning she woke up without complaint.  She had a bowel movement in the morning.  She went to church and afterwards out to eat.  On the way home she developed acute onset of lower abdominal pain that she states is the worst pain she is ever had.  No fever or chills.  She had 2 episodes of emesis that time.  No symptoms of hematemesis melena dark tarry stools or bright red blood per rectum.  Since that time she has been nauseated and has had nothing more to eat since that meal after church on Sunday.  Her abdomen is been distended and she has had waves of abdominal cramping in her lower abdomen.  No symptoms of fever chills cough or congestion.  No symptoms of dysuria frequency or urgency.  She denies any diarrhea.  No other close contacts have been ill.   In the emergency room her blood pressure was 113/73 heart rate 70 respiratory rate 16 temperature 36.8 oxygen saturation 92% on room air.   Serology: White count 14,300 with no differential hemoglobin 13.5 hematocrit 41.5 and a platelet count of 262,000.  Sodium 136 testing 4.1 chloride 96 bicarb 30 BUN 23 creatinine 1.1 and a blood sugar of 96. calcium 10.0 alkaline phosphatase 89 ALT 18 AST 22 total bilirubin 2.1 total protein 7.2 albumin 4.2.  Serum lactate 1.4.CT scan abdomen pelvis showed small bowel obstruction with transition point in the right lower quadrant.  Wall thickening of the loop of small bowel in the right lower quadrant near the transition point.  Correlate clinically for signs and symptoms of infectious or inflammatory enteritis.  Increased size and number of lymph nodes in the small bowel mesentery which may be reactive.  Thickening of the endometrial stripe measuring 8 mm which is abnormal in a postmenopausal female with recommendations of nonemergent gynecology evaluation and pelvic ultrasound for further characterization.  Noncalcified material in the dependent gallbladder which may represent sludge or noncalcified stones.  Sigmoid colonic diverticulosis.   Past medical history: Hypertension, hyperlipidemia, hypothyroidism.  No prior surgeries noted.???????  Review of Systems     All 13 point review of systems were reviewed with the patient and are negative except as specified in the HPI.???????  Physical Exam/Objective Vitals & Measurements most recent past 24 hours    Hemodynamics   Neurologic   Patient Weight    Patient Height  None Reported           General:  Alert and oriented, No acute distress.         Eye:  Extraocular movements are intact, Vision unchanged       HEENT:  Normocephalic, Normal hearing       Neck:  Supple, Non-tender       Respiratory:  Lungs are clear to auscultation, Respirations are non-labored, Breath sounds are equal, No chest wall tenderness.         Cardiovascular:  Regular rate, Normal rhythm, No murmur, No gallop, Normal peripheral perfusion, Good pulses equal in all extremities, No edema.          Gastrointestinal: Distended, bilateral lower quadrant tenderness right greater than left, hypoactive bowel sounds, no evidence of hepatosplenomegaly.       Lymphatics:  No lymphadenopathy neck       Musculoskeletal:  Normal range of motion, Normal strength       Integumentary:  Warm, Dry, No rash.         Feet:  Normal by visual exam, Normal pulses, Sensation intact.         Neurologic:  Alert, Oriented, Normal motor function       Psychiatric:  Cooperative, Appropriate mood & affect, Normal judgment.  ???????    Assessment/Plan      1. Small bowel obstruction   K56.609  Patient presents with small bowel obstruction with a distinct transition point.  Surgery has been consulted.  She brought it is inpatient care.  IV fluid rehydration as well as IV analgesic and antiemetic therapy as needed.  An NG tube will be placed to low intermittent wall suction with serial physical and radiographic examinations for further evaluation.  Will continue to manage conservatively with hopes that we can avoid surgical intervention.   2. Enteritis   K52.9  Noted on CT imaging.  This is noted heavily at the transition point.  This may be the source of her bowel obstruction as she did not have any prior surgeries to yield scar tissue.  She will given IV fluid rehydration.  IV antibiotic therapy.  Will reevaluate clinically.   3. Acute abdominal pain   R10.9  As above noted.  Secondary small bowel obstruction.  Continue allergy therapy and IV fluid rehydration.  Managing a small bowel obstruction as noted above.  Surgical consultation.   4. Hypertension, benign   I10  Blood pressure relatively stable this time.  Patient is n.p.o. for now.  Will hold initiating her home medication.  May require IV medication such as labetalol or enalapril to aid in blood pressure reduction if needed.   5. Mixed hyperlipidemia   E78.2  Noted.  Will hold off statin therapy at this time.   6. Adult onset hypothyroidism   E03.8  Thyroid function testing pending.  Will restart patient's thyroid therapy as soon as capable.   GI and DVT prophylaxis have been addressed.  Home medications were reviewed and appropriate medications ordered at this time. ???????  Code Status   None Recorded   Chronic Problem List    Acute abdominal pain  Adult onset hypothyroidism  Body mass index (BMI) of 35.0 to 35.9  Breast screening declined  Colonoscopy refused  Enteritis  Hypertension, benign  Mammogram declined  Mixed hyperlipidemia  Small bowel obstruction  Procedure/Surgical History  ?Colonoscopy     Medications   Home Medications (5) Active  atenolol 50 mg oral tablet 50 mg = 1 Tablet, Orally, Daily  atorvastatin 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  Centrum Silver oral tablet 1 Tablet, Orally, QAM  Citracal + D 1 Tablet, Orally, QAM  Synthroid 88 mCg (0.088 mg) oral tablet 88 mCg = 1 Tablet, Orally, Daily, GENERIC ONLY!!!!  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 10/21/24 00:00:00 TO 10/22/24 16:00:25  None Reported  PRN Medications (0600 - 0559) from 10/21 - 10/22  None Reported  Allergies   No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Exercise   Exercise frequency: Does Not Exercise. Exercise type: Active with house work.   Home/Environment   Lives with Spouse.   Nutrition/Health   Diet: Regular. Caffeine intake amount: Diet coke daily.   Sexual Orientation and Gender Identity   What is your current gender identity? (check all that apply) Female. Which of the following do you identify most closely with? (check all that apply) Heterosexual (or straight).   Substance Abuse   Denies   Tobacco   Tobacco Use: Never (less than 100 in lifetime).  Family History   A-fib...: Mother.  Leukemia: Brother.Negative: Brother.  Relapsing polychondritis....: Son.   Deceased Family Member(s)  Relationship: Mother, Age: Unknown  Relationship: Brother, Age: Unknown, Cause: leukemia  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 14.3 k/cumm High (10/22/24 12:12:00)  RBC: 5.23 million/cumm High (10/22/24 12:12:00)  Hgb: 13.5 GM/dL (10/22/24 12:12:00)  Hct: 41.5 % (10/22/24 12:12:00)  MCV: 79 fL Low (10/22/24 12:12:00)  MCH: 25.8 pg Low (10/22/24 12:12:00)  MCHC: 32.5 GM/dL (10/22/24 12:12:00)  RDW: 14.2 % (10/22/24 12:12:00)  Platelet: 262 k/cumm (10/22/24 12:12:00)  MPV: 11 fL (10/22/24 12:12:00)  Chemistry:  Sodium SerPl QN: 135 mmol/L (10/22/24 12:12:00)  Potassium SerPl QN: 4.2 mmol/L (10/22/24 12:12:00)  Chloride SerPl QN: 95 mmol/L Low (10/22/24 12:12:00)  Carbon Dioxide SerPl QN: 33 mmol/L High (10/22/24 12:12:00)  Anion Gap: 7 mmol/L (10/22/24 12:12:00)  BUN SerPl QN: 22 mg/dL High (10/22/24 12:12:00)  Creatinine SerPl QN: 1.02 mg/dL (10/22/24 12:12:00)  Estimated GFR (CKD-EPI, no race): 55 mL/min/1.73m2 Low (10/22/24 12:12:00)  Estimated CRCL (CG): 41 mL/min Low (10/22/24 12:12:00)  Glucose SerPl QN: 93 mg/dL (10/22/24 12:12:00)  Calcium Total SerPl QN: 10 mg/dL (10/22/24 12:12:00)  Alkaline Phos SerPl QN: 89 Units/L (10/22/24 12:12:00)  ALT SerPl QN: 18 Units/L (10/22/24 12:12:00)  AST SerPl QN: 22 Units/L (10/22/24 12:12:00)  Bilirubin Direct SerPl QN: 0.4 mg/dL High (10/22/24 12:12:00)  Bilirubin Total SerPl QN: 2.1 mg/dL High (10/22/24 12:12:00)  Total Protein SerPl QN: 7.2 GM/dL (10/22/24 12:12:00)  Albumin SerPl QN: 4.2 GM/dL (10/22/24 12:12:00)  Lactate Venous Pl QN: 1.4 mmol/L (10/22/24 12:12:00)  Lactate Bld Venous QN: 2.6 mmol/L High (10/22/24 12:23:00)  Sodium, ePOC: 136 mmol/L (10/22/24 12:23:00)  Potassium, ePOC: 4.1 mmol/L (10/22/24 12:23:00)  Ionized Ca, ePOC: 1.23 mmol/L (10/22/24 12:23:00)  Chloride, ePOC: 96 mmol/L Low (10/22/24 12:23:00)  CO2-Tot, ePOC: 30 mmol/L High (10/22/24 12:23:00)  Glucose, ePOC: 96 mg/dL (10/22/24 12:23:00)  BUN, ePOC: 23 mg/dL High (10/22/24 12:23:00)  Creatinine, ePOC: 1.1 mg/dL (10/22/24 12:23:00)  Anion Gap, ePOC: 15 mmol/L (10/22/24 12:23:00)  Estimated CRCL (CG), POC: 38 mL/min Low (10/22/24 12:23:00)  Estimated GFR (CKD-EPI, no race), POC: 50 mL/min/1.73m2 Low (10/22/24 12:23:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 10/22/2024 13:38 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  Small bowel obstruction with transition point in the right lowerquadrant.2.  Wall thickening of a loop of small bowel in the right lowerquadrant near the transition point. Correlate clinically for signsand symptoms of infectious or inflammatory enteritis.3.  Increased size and number of the lymph nodes in the small bowelmesentery, which may be reactive.4.  Thickening of the endometrial stripe measuring 8 mm., Which isabnormal in a postmenopausal female Recommend nonemergent gynecologyevaluation and pelvic ultrasound for further characterization.5.  Noncalcified material in the dependent gallbladder may representsludge or noncalcified stones.6.  Sigmoid colonic diverticulosis.7.  Additional nonacute and incidental findings as above.Thank you for consulting our team of subspecialty radiologists at Radiology. Please contact us with any questions.                Signature Line Electronically Signed on 10/22/24 16:00 ________________________________________________________ MD