Age: 78.0
Sex: M
Vaccine: FLU4
Symptoms: Urine leukocyte esterase, Urobilinogen urine, Vomiting, White blood cell count increased, White blood cells urine positive
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: on November 15, 2022 04:58   Verified By: on November 15, 2022 04:58   Encounter Info: Inpatient, 11/15/22 -     * Final Report *        Chief Complaint   vomiting  History of Present Illness/Subjective     78 year old male s/p right inguinal hernia repair on 10/3/22, presented complaining of abd pain and generalized weakness. Pt endorses diffuse lower abdominal pain w/ associated generalized weakness, nausea, and 3-4 episodes of emesis for the past several hours today. Last BM 6 hrs ago.  He denies fevers, chest pain, dyspnea, cough, or other complaints.  Pt has hx of SBO in July, treated with conservative management and his last BM was today. Has not passed gas since last bowel movement.   In the ED, the provider made multiple attempts to place an NG tube which were unsuccessful and resulted in some mild epistaxis which is since resolved, patient is requesting no additional attempts be made at this time for placement of the NG tube understanding that there is a risk of further obstruction and complications the longer we wait to decompress the stomach including possible aspiration of stomach contents and patient is experiencing vomiting since arriving to the floor however he understands he is concerns and still would like to delay additional attempts to place an NG tube for the time being and and rest in the interim.   As per the ED provider, the Surgeon on call was requested to consult on the patient while in the ED, he agreed to see the patient in the am and recommended admission to medicine in the interim.  I spent greater than 50 minutes in the evaluation and management of this patient with more than 50% of the time spent counseling and/or coordinating care.  I counseled the patient and/or family about the findings, differential diagnoses, my assessment, recommendations, and plan.  I coordinated care with the multidisciplinary healthcare team.  Review of Systems     A complete, 13-system review was performed and was negative except for as noted in the HPI.  Physical Exam/Objective  Vital Signs (most recent and range for last 24 hours)  Temp (CEL) 36.7 (36.7-36.7)  Temp (FAHR) 98.1 (98.1-98.1), BP 146/72 (146-146)/(72-72), HR 83 (82-87), RR 22 (20-22), O2Sat 99 (97-99)     Patient Weight  Current Daily Weight:    80.7 kg    11/15/22  BMI:    25.7    11/15/22    Overweight (BMI 25-29.9) Patient Height  Current Height:    177.3 cm    11/15/22        Constitutional:  No acute distress,  well-nourished Eyes:  PERRL,  EOMI,  normal conjunctiva,  no scleral icterus ENMT:  Moist oral mucosa Neck:  Supple, non-tender, intact range of motion Respiratory:  Lungs CTAB Cardiovascular:  Regular rate and rhythm Gastrointestinal:  Soft, non-tender, distended, absent bowel sounds Musculoskeletal:  No joint swelling, no deformity, intact ROM Integumentary:  Intact, warm, dry no rashes Neurologic: Alert & Oriented x 3, no cognitive impairment,  no focal deficits Psychiatric:  Cooperative, appropriate mood and affect  Assessment/Plan      1. SBO (small bowel obstruction)   K56.609   2. Hx of hernia repair   Z98.890  General surgery consult would be appreciated  As above patient is temporarily refusing NG tube, will maintain elevation of bed 30 degrees or greater in the interim  QTC is borderline will need to monitor it with frequent EKGs in between doses of Zofran and discontinue use if lengthening  Pain control with as little opioid therapy as possible to superimposed ileus  Strict n.p.o., continue IV fluid, serial exams, trend lactate, trend CBC and electrolytes  continue Rocephin Flagyl   3. High cholesterol   E78.00   4. Hypertension   I10   5. S/P AVR (aortic valve replacement)   Z95.2  Noted continue home medications as appropriate   6. COPD without exacerbation   J44.9  resp eval, cont home meds as appropriate   Orders:   fluticasone-vilanterol, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, Daily, 11/15/22 9:00:00  heparin, 5,000 Units, Subcutaneous, Injection, Q8H, Routine, 11/15/22 3:00:00   HYDROmorphone, 0.5 mg, IV Push, Injection, Q4H, PRN, Pain Severe IV (7-10 out of 10), 11/15/22 2:05:00  Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 11/15/22 2:05:00, 75 mL/hr, Clinical Weight  morphine, 2 mg, IV Push, Injection, Q4H, PRN, Pain Moderate IV (4-6 out of 10), 11/15/22 2:05:00  umeclidinium, 1 Puff, Inhalation, Aerosol Powder, MDI/DPI Inhaler Treatment, Daily, 11/15/22 9:00:00  Admit to Inpatient  Auto Diff  Call Blood Glucose  Call Diastolic Blood Pressure  Call Heart Rate  Call Mental Status Changes  Call O2 Saturation  Call Respiratory Distress  Call Respiratory Rate  Call Systolic Blood Pressure  Call Temperature  Call Urine Output  CBC w/Differential  Comp Metabolic Panel  Electrocardiogram  Fall Precautions  Gluc-Strip POC  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Lactate Pl Venous QN  Level of Care  Magnesium SerPl QN  Medical Service  Nasogastric Tube  Nasogastric Tube Output  Nasogastric Tube Output  NPO  OT Evaluation and Treatment  Phosphorus SerPl QN  PT Evaluation and Treatment  Resp Evaluation or Assessment  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  Telemetry Class III 24hr Recommendation  Vital Signs  Weight  Weight  Patient is DNR/DNI  Code Status   Resuscitation Status - Ordered    -- 11/15/22 2:05:00, DNR/DNI/Comprehensive Care   Chronic Problem List    Dilated cardiomyopathy  High cholesterol  Hypertension  Inguinal hernia of right side without obstruction or gangrene  S/P AVR (aortic valve replacement)  S/P placement of cardiac pacemaker  Procedure/Surgical History  ?Excision of left shoulder cyst (07/01/2020) ?Excision of left temporal cyst (07/01/2020) ?PPM implantation (01/18/2018) ?cardioversion (11/06/2017) ?AVR & Maze Procedure (05/09/2017) ?Tonsillectomy (1948) ?Cardiac catheterisation ?Cataracts, bilateral ?cyst removed from back ?Robot AsstLaparoscopic Right Inguinal Hernia Repair possible Left   Surgical History Internal  10/03/2022    Hernia Repair Inguinal   05/09/2017    Aortic Valve Replacement     Medications   Home Medications (10) Active  amiodarone 100 mg oral tablet 100 mg = 1 Tablet, Orally, QAM  amLODIPine 5 mg oral tablet 5 mg = 1 Tablet, Orally, QAM  aspirin 81 mg oral tablet 81 mg, Orally, Daily  carvedilol 25 mg oral tablet 25 mg = 1 Tablet, Orally, BID  Colace 100 mg oral capsule 100 mg = 1 Capsule, PRN, Orally, BID  furosemide 20 mg oral tablet 20 mg = 1 Tablet, Orally, QAM  Spiriva 18 mcg inhalation capsule 18 mCg = 1 Capsule, Inhalation, QAM  Vitamin B12 1000 mCg oral tablet 1,000 mCg = 1 Tablet, Orally, QAM  Vitamin C 1000 mg oral tablet 1,000 mg = 1 Tablet, Orally, QAM  Wixela Inhub 250 mCg-50 mCg inhalation powder 1 Puff, Inhalation, BID  Active Scheduled Inpatient Medications  fluticasone-vilanterol (Breo Ellipta 200 mCg-25 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 11/15/22 09:00:00  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 11/15/22 03:00:00  umeclidinium (Incruse Ellipta 62.5 mCg inhalation powder), Aerosol Powder, 1 Puff, Inhalation, Daily, Start: 11/15/22 09:00:00  Lactated Ringers  1,000 mL IV  75 mL/hr       One-Time Medications Given 11/14/22 00:00:00 TO 11/15/22 04:58:32  ondansetron (Zofran), Injection, 4 mg, IV Push, ONCE, (1 DOSE 11/15/22 02:47:00)  PRN Medications (0600 - 0559) from 11/14 - 11/15  HYDROmorphone, 0.5 mg, IV Push, Q4H, 1  Dose(s)   morphine, 2 mg, IV Push, Q4H, 0  Dose(s)   Allergies   lisinopril (facial swelling)  Social History    Alcohol   Current, Beer, 1-2 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Home/Environment   Lives with Spouse. Living situation: Home/Independent.   Nutrition/Health   Diet: Regular.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   Arthritis: Mother.  Cancer: Father.  Heart disease: Mother.  Liver cancer..: Father.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 17 k/cumm High (11/15/22 02:12:00)  RBC: 5.09 million/cumm (11/15/22 02:12:00)  Hgb: 14.3 GM/dL (11/15/22 02:12:00)  Hct: 42.8 % (11/15/22 02:12:00)  MCV: 84 fL (11/15/22 02:12:00)  MCH: 28.1 pg (11/15/22 02:12:00)  MCHC: 33.3 GM/dL (11/15/22 02:12:00)  RDW: 17.2 % High (11/15/22 02:12:00)  Platelet: 265 k/cumm (11/15/22 02:12:00)  MPV: 8.9 fL (11/15/22 02:12:00)  Neutrophils %: 92 % (11/15/22 02:12:00)  Lymphocytes %: 2 % (11/15/22 02:12:00)  Monocytes %: 6 % (11/15/22 02:12:00)  Eosinophils %: 0 % (11/15/22 02:12:00)  Basophils %: 0 % (11/15/22 02:12:00)  Absolute Neutrophil: 15.5 k/cumm High (11/15/22 02:12:00)  Absolute Lymphocyte: 0.3 k/cumm Low (11/15/22 02:12:00)  Absolute Monocyte: 1 k/cumm (11/15/22 02:12:00)  Absolute Eosinophil: 0 k/cumm (11/15/22 02:12:00)  Absolute Basophil: 0.1 k/cumm (11/15/22 02:12:00)  Chemistry:  Sodium SerPl QN: 141 mmol/L (11/15/22 02:12:00)  Potassium SerPl QN: 4.3 mmol/L (11/15/22 02:12:00)  Chloride SerPl QN: 100 mmol/L (11/15/22 02:12:00)  Carbon Dioxide SerPl QN: 23 mmol/L (11/15/22 02:12:00)  Anion Gap: 18 mmol/L High (11/15/22 02:12:00)  BUN SerPl QN: 25 mg/dL High (11/15/22 02:12:00)  Creatinine SerPl QN: 1.21 mg/dL (11/15/22 02:12:00)  Estimated GFR (CKD-EPI, no race): 61 mL/min/1.73m2 (11/15/22 02:12:00)  Estimated CRCL (CG): 54 mL/min Low (11/15/22 02:12:00)  Glucose SerPl QN: 144 mg/dL High (11/15/22 02:12:00)  Calcium Total SerPl QN: 9.7 mg/dL (11/15/22 02:12:00)  Phosphorus SerPl QN: 3.3 mg/dL (11/15/22 02:12:00)  Alkaline Phos SerPl QN: 80 Units/L (11/15/22 02:12:00)  ALT SerPl QN: 9 Units/L (11/15/22 02:12:00)  AST SerPl QN: 14 Units/L (11/15/22 02:12:00)  Bilirubin Total SerPl QN: 0.8 mg/dL (11/15/22 02:12:00)  Total Protein SerPl QN: 7.5 GM/dL (11/15/22 02:12:00)  Albumin SerPl QN: 4.4 GM/dL (11/15/22 02:12:00)  Magnesium SerPl QN: 2 mg/dL (11/15/22 02:12:00)  Troponin-I High Sensitivity: 9 ng/L (11/14/22 21:50:00)  Lactate Venous Pl QN: 1 mmol/L (11/15/22 02:12:00)  Gluc-Strip, POC: 155 mg/dL High (11/15/22 02:49:00)  Coagulation:  PT: 12.1 seconds (11/14/22 21:50:00)  INR: 1.06 (11/14/22 21:50:00)  Urine Studies:  Color: Yellow (11/14/22 23:53:00)  Clarity: Clear (11/14/22 23:53:00)  Specific Gravity: 1.020 (11/14/22 23:53:00)  pH: 5.5 (11/14/22 23:53:00)  Protein: TRACE. Abnormal (11/14/22 23:53:00)  Glucose: NEGATIVE (11/14/22 23:53:00)  Ketones: TRACE. Abnormal (11/14/22 23:53:00)  Bilirubin: SC Small Abnormal (11/14/22 23:53:00)  Hgb Ur: NEGATIVE (11/14/22 23:53:00)  Nitrite: NEGATIVE (11/14/22 23:53:00)  Urobilinogen: 1.0. (11/14/22 23:53:00)  Leukocyte Esterase Ur: NEGATIVE (11/14/22 23:53:00)  WBC: 6-10 Abnormal (11/14/22 23:53:00)  RBC: 3-5 Abnormal (11/14/22 23:53:00)  Bacteria: TRACE. (11/14/22 23:53:00)  Squamous Epithelial: Few (11/14/22 23:53:00)  Mucous: PRESENT. (11/14/22 23:53:00)  Hyaline Casts: 3-5 (11/14/22 23:53:00)  All Other Labs:  COVID 19 Specimen Source: Nasopharyngeal (11/14/22 23:47:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (11/14/22 23:47:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 11/14/2022 23:09 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  Findings concerning for recurrent high-grade small bowelobstruction.Results were communicated and receipt was documented in the System.Thank you for consulting our team of subspecialty radiologists.                Signature Line Electronically Signed on 11/15/22 04:58  ________________________________________________________