Age: 71.0
Sex: F
Vaccine: COVID19
Symptoms: Cholelithiasis, Chromaturia, Coagulation test, Colectomy, Colon cancer
Clinical narrative: Document Type: Internal Medicine IP Consultation   Document Subject: Consult Note   Performed By: MD on May 25, 2023 16:18 EDT   Verified By: MD on May 25, 2023 16:18 EDT   Encounter Info: Inpatient, 05/25/23 -     * Final Report *            Referral Source  None None   Subjective      Reason for consult: Medical management of chronic medical problems  Primary service: Surgery  Consulting service: Internal medicine  Patient is a 73-year-old female patient who was recently diagnosed with adenocarcinoma of the ascending colon and a suspicious lesion of the kidney has been under care of Dr. who took her to the OR today for ascending colon colectomy and descending colon resection.   patient had successful resection and has been placed in ICU.  Patient also had cholecystectomy done due to having cholelithiasis prior to this admission.  Patient has seen a kidney doctor who plans to later work with the renal cancer.  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 last 24 hours  T: 36.5 °C (Axillary)  TMIN: 36.4 °C (Temporal Artery)  TMAX: 36.6 °C (Temporal Artery)  BP: 111/56  HR: 78 (Peripheral)  HR: 78 (Monitored)  RR: 20  SpO2: 94%  Oxygen Therapy: Room air  WT: 122.7 kg  BMI: 44   Hemodynamics   Neurologic   Patient Weight  Current Daily Weight:    122.7 kg    05/25/23  Previous Daily Weight:    122.7 kg    05/25/23  BMI:    44    05/25/23    Morbid Obesity (BMI > = 40) Patient Height  Current Height:    167 cm    05/25/23     Vent Settings - Last Documented  Positive End Expiratory Pressu1.7            05/25/23 13:25:00  ETCO2                         16             05/25/23 13:25:00  Oxygen Therapy                Room air       05/25/23 14:15:00     I/O TOTALS ONLY - Last 24 hrs (0600-0559) from 05/24 - 05/25  Total Intake 0.00 mL    Total Output 0.00 mL     Balance 0.00 mL     Invasive Lines  Hand, Right Angiocath - Closed 20 ga 5/25/2023 07:35   Applied, Transparent     Code Status  Resuscitation Status - Ordered    -- 05/25/23 14:15:00 EDT, Full Code     General: Alert and oriented, No Acute distress Eye: Pupils are equal, round and reactive to light HEENT: Normocephalic, atraumatic Neck: Supple, normal range of motion Oropharynx: No erythema or drainage. Respiratory: Lungs are clear to auscultation. No added sounds Cardiovascular: Normal rate, Regular rhythm. s1 s2 positive Gastrointestinal: Soft, Non-tender. BS present all 4 quadrants Musculoskeletal: Normal range of motion, No focal tenderness Integumentary: Warm, Dry, No rash Neurologic: No focal weakness. Sensation intact. Normal mood and affect. cranial nerves grossly intact   Assessment/Plan       1. Colon adenocarcinoma   C18.9  s/p surgery day #0  management by surgery  pain control via norco and morphine.      2. Cancer of kidney   C64.9  This is to be evaluated once patient is stable and outpatient.  She has been seen by nephrology earlier.   3. Hypothyroidism   E03.9  resume home medications.   4. Severe obesity   E66.01  Noted.   5. Chronic GERD   K21.9  on PPI   6. Depression   F32.A  resume home meds.   Orders:   hydroCODONE-acetaminophen, 1 Tablet, Orally, Tablet, Q6H, PRN, Pain, Mild (1-3 out of 10), 05/25/23 16:17:00 EDT  levothyroxine, 200 mCg, Orally, Tablet, Daily, 05/26/23 6:00:00 EDT  morphine, 2 mg, IV Push, Injection, Q4H, PRN, Pain, Mild (1-3 out of 10), 05/25/23 16:17:00 EDT  sertraline, 100 mg, Orally, Tablet, Daily, 05/26/23 9:00:00 EDT    Chronic Problem List    Gastroparesis  Severe obesity  Procedure/Surgical History  ?Colonoscopy (03/17/2023) ?EGD - Esophagogastroduodenoscopy (07/19/2022)   Surgical History Internal  05/25/2023    Laparoscopic Exploration     MD  03/17/2023    Colonscpy Snare Tmr Polyp Lsn     MD  07/19/2022    EGD Bx     MD  Medications  Home Medications (5) Active  cyanocobalamin 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, Daily  levothyroxine 200 mCg (0.2 mg) oral tablet 200 mCg = 1 Tablet, Orally, Daily  omeprazole 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, Daily  oxyBUTYnin 5 mg oral tablet 5 mg = 1 Tablet, Orally, TID  sertraline 100 mg, Orally, Daily  Active Scheduled Inpatient Medications  ceFAZolin, Injection, 3 GM, IVPB, X 1 Dose, Indication: Other (MUST specify in Comments), Start: 05/25/23 11:46:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8, Start: 05/25/23 22:00:00  levothyroxine, Tablet, 200 mCg, Orally, Daily, Start: 05/26/23 06:00:00  pantoprazole, Injection, 40 mg, IV Push, Daily, Start: 05/26/23 09:00:00  Zosyn, Injection, 3.375 GM, IVPB, Q8H, Indication: Intra-Abdominal Infection, Start: 05/25/23 15:00:00  sertraline, Tablet, 100 mg, Orally, Daily, Start: 05/26/23 09:00:00  Sodium Chloride 0.9%  1,000 mL IV  125 mL/hr       One-Time Medications Given 05/24/23 00:00:00 TO 05/25/23 16:18:23  fentaNYL, Injection, 25 mCg, IV Push, ONCE, (1 DOSE 05/25/23 14:20:00)  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 7,500 Units, Subcutaneous, ONCE, (1 DOSE 05/25/23 07:52:00)  indocyanine green, Injection, 2.5 mg, IV Push, ONCE, (1 DOSE 05/25/23 07:50:00)  PRN Medications (0600 - 0559) from 05/24 - 05/25  HYDROmorphone, 1 mg, IV Push, Q4H, 0  Dose(s)   acetaminophen, 650 mg, Orally, Q4H, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, Q4H, 0  Dose(s)   hydroCODONE-acetaminophen, 1 Tablet, Orally, Q6H, 0  Dose(s)   morphine, 2 mg, IV Push, Q4H, 0  Dose(s)   ondansetron, 4 mg, IV Push, Q4, 0  Dose(s)   Allergies   NKA  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.    Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Coagulation:  PT: 11.6 seconds (05/25/23 09:06:00)  INR: 1.02 (05/25/23 09:06:00)  aPTT: 35 seconds (05/25/23 09:06:00)  Urine Studies:  Color: Light-Yellow (05/25/23 08:49:00)  Clarity: Clear (05/25/23 08:49:00)  Specific Gravity: 1.018 (05/25/23 08:49:00)  pH: 5 (05/25/23 08:49:00)  Protein: NEGATIVE (05/25/23 08:49:00)  Glucose: Normal (05/25/23 08:49:00)  Ketones: 10 Abnormal (05/25/23 08:49:00)  Bilirubin: NEGATIVE (05/25/23 08:49:00)  Hgb Ur: NEGATIVE (05/25/23 08:49:00)  Nitrite: NEGATIVE (05/25/23 08:49:00)  Urobilinogen: Normal (05/25/23 08:49:00)  Leukocyte Esterase Ur: NEGATIVE (05/25/23 08:49:00)  WBC: 0-5 (05/25/23 08:49:00)  RBC: 0-2 (05/25/23 08:49:00)  Bacteria: NONE (05/25/23 08:49:00)  Squamous Epithelial: NONE (05/25/23 08:49:00)  Hyaline Casts: 0-2 (05/25/23 08:49:00)  All Other Labs:  ABO Rh: AB Pos (05/25/23 07:28:00)  IAT Interp: Neg (05/25/23 07:28:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits  No radiology results found in the last 24 hours.          Signature Line Electronically Signed on 05/25/23 16:18 EDT ________________________________________________________ MD