Age: 67.0
Sex: M
Vaccine: COVID19
Symptoms: Ascites, Biliary dilatation, Computerised tomogram abdomen abnormal, Decreased appetite, Intervertebral disc degeneration
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on November 11, 2022 08:14 EST   Verified By: MD on November 11, 2022 08:14 EST   Encounter Info: Hospital, Outpatient in a Bed, 11/11/22 - 11/11/22    * Final Report *        Chief Complaint   liver mets  History of Present Illness/Subjective     abnormal ct scan with liver mets, needs endoscopic evaluation of gi tract as  possible source  Review of Systems     Constitutional: No fever, No chills, No sweats, No weakness, No fatigue, No decreased activity, wt loss Eyes: No Icterus ENMT: No nasal congestion, No sore throat Respiratory: No SOB, No cough Cardiovascular: No Chest pain, No palpitations, No peripheral edema Gastrointestinal: No nausea, vomiting, No diarrhea, No constipation, No Heartburn, Abdominal pain, No hematemesis Genitourinary: No dysuria, No hematuria, No change in urine stream Hema/Lymph: No bruising tendency, No bleeding tendency, No swollen lymph glands Endocrine: No excessive thirst, No polyuria, No cold intolerance, No heat intolerance, No excessive hunger Immunologic: No immunocompromised, No recurrent fevers, No recurrent infections, No malaise Lymphatics: No lymphadenopathy neck, Axilla, Groin Musculoskeletal: Normal gait Integumentary: Warm, Dry, Pink, No pallor, No rash, No Pruritus, No Abrasions, No Breakdown, No Burns, No Dryness, No Petechiae, No Skin Lesion, No Hypertrophic scar, No Keloid Neurologic: Alert, Oriented, No Abnormal balance, No Confusion, No Numbness, No Tingling, No Headache Psychiatric:  No Anxiety, No Depression, No Mania, Non-Suicidal, Non-Delusional, No Halluciations  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.5 (36.5-36.5)  Temp (FAHR) 97.7 (97.7-97.7), BP 201/98 (178-201)/(91-98), HR 83 (83-86), RR 16 (16-16), O2Sat 98 (98-98)     Patient Weight  Current Daily Weight:    55 kg    11/11/22  BMI:    19.5    11/11/22    Normal Weight (BMI 18.5-24.9) Patient Height  Current Height:    168 cm    11/11/22        General: Alert and oriented, No acute distress Eye: PERRL, EOMI, Normal conjunctiva HENT: Normocephalic Neck: Supple, Non-tender, No JVD, No lymphadenopathy, No thyromegaly Cardiovascular: Regular rate, Normal rhythm, No murmur, S1, S2 Breast: No mass, No tenderness, No discharge Respiratory: Lungs CTA, Non-labored, BS equal Gastrointestinal: Soft,-tender, Non-distended, Normal bowel sounds, No organomegaly Lymphatics: No lymphadenopathy neck, Axilla, Groin Musculoskeletal: Normal gait Integumentary: Warm, Dry, Pink, No pallor, No rash Neurologic: Alert, Oriented, No focal defects, CN II-XII intact Psychiatric: Cooperative, Appropriate & affect, Normal judgement       Assessment/Plan       1. Metastasis to liver   C78.7  Needs endoscopic evaluation of GI tract will schedule EGD and Colonoscopy. Surgical risks and benefits explained to patient. Included but not limited to infection, hemmorage, and perforation. Patient understands and wished to comply.    patient verbalize understanding and compliance with the plan will proceed as scheduled   Orders:   Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 11/11/22 7:14:00 EST, 100 mL/hr  Message to Nursing  Message to Nursing  Procedure/Test Scheduled Date/Time  Verify per Nursing (Specify)  Verify per Nursing (Specify)   Code Status   None Recorded   Chronic Problem List    No qualifying data       Medications   Home Medications (1) Active  Lovenox   Active Scheduled Inpatient Medications  Lactated Ringers  1,000 mL IV  100 mL/hr       One-Time Medications Given 11/10/22 00:00:00 TO 11/11/22 08:13:19  None Reported  PRN Medications (0600 - 0559) from 11/10 - 11/11  None Reported  Allergies   NKA             Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.             Signature Line Electronically Signed on 11/11/22 08:14 EST ________________________________________________________ MD