Age: 80.0
Sex: M
Vaccine: COVID19
Symptoms: Hiatus hernia, Laparoscopic surgery, Lipase increased, Liver function test abnormal, Lymphocyte count
Clinical narrative: Document Type: History and Physical   Document Subject: History & Physical Note   Performed By:  DO on November 01, 2022 06:50 EDT   Verified By: DO on November 01, 2022 06:50 EDT   Encounter Info: Hospital, Inpatient, 10/31/22 -     * Final Report *        Chief Complaint   Abdominal pain  History of Present Illness/Subjective     The following history was obtained from the patient as well as from chart review as the patient was A&O x3 at times he was confused of his situation, confusing his current situation for his recent admission for septic arthritis.  This is an 81-year-old male w/ a pmhx of DM II, HTN, hLD, CAD s/p CABG, OA, former smoker, who presented with cc of epigastric abdominal pain starting at above his umbilicus and radiating to the chest off and on x 1 week.  He states that he frequently has a feeling like he is abdomen is full early in meals and like he needed to belch.  He also states that he has had intermittent episodes of lightheadedness when standing up which has required him several times to have to take a seat.  He denies fever, SOB, n/v/d, constipation or cough.  He states that nothing makes the pain better or worse.   In the ED he had significantly elevated lipase as well as a CT scan demonstrating pancreatitis as well as cholelithiasis but no acute cholecystitis, suspicion for gallstone pancreatitis prompted the ED provider to reach out to both Dr. of general surgery and Dr. of gastroenterology both of whom recommended admitting to the hospitalist for further work-up and potential cholecystectomy after resolution of pancreatitis.  Patient will have an MRCP in the a.m.  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 (36.4-36.7)  Temp (FAHR) 98.1 (97.5-98.1), BP 145/62 (128-145)/(62-71), HR 58 (47-58), RR 18 (18-18), O2Sat 97 (96-97) Neurologic (most recent and range for last 24 hours)  GCS 15(15-15)     Patient Weight  Current Daily Weight:    93.3 kg    11/01/22  Previous Daily Weight:    87.2 kg    10/31/22  Difference from Previous:    6.100 kg  BMI:    28.5    10/31/22    Overweight (BMI 25-29.9) Patient Height  Current Height:    175 cm    11/01/22        General:  Alert and oriented, No acute distress.  Elderly appearing male Eye:  Pupils are equal, round and reactive to light, Normal conjunctiva.   HENT:  Normocephalic, atraumatic Neck:  Non-tender, No jugular venous distention, Cardiovascular:  Regular rate, Normal rhythm, S1, S2.   Respiratory: CTABL, no respiratory distress Gastrointestinal:  Soft, tender only in the epigastrium upon moderate to deep palpation, Non-distended, Normal bowel sounds, Integumentary:  Warm, Dry, Intact.  There is a sizable ecchymotic process in different stages of healing on his right posterior chest wall from which he states is from a recent fall this process is NOT near the flanks and is unilateral Neurologic:  Alert, Oriented x3 some age-related mental decline, Normal sensory, Normal motor function, No focal defects, Psychiatric:  Cooperative, Appropriate mood & affect.    Assessment/Plan      1. Acute pancreatitis   K85.90   2. Abnormal LFTs   R79.89   3. Cholelithiasis without cholecystitis   K80.20  Admit to MedSurg  MRCP stat  Trend LFTs and CBC  N.p.o.  Continue IV hydration  Continue Zosyn  Would appreciate GI and surgery evaluations  Most likely etiology of pancreatitis is gallstone pancreatitis versus other   4. Orthostatic hypotension   I95.1  Likely secondary to #1  After IV fluid resuscitation can repeat orthostatics to see if symptoms are improved   5. Type 2 diabetes mellitus   E11.9  POC glucose checks insulin sliding scale hold home medicines for now n.p.o.   6. BPH (benign prostatic hyperplasia)   N40.0   7. Hypertension   I10   8. Hyperlipidemia   E78.5   9. S/P CABG (coronary artery bypass graft)   Z95.1   10. CKD (chronic kidney disease)   N18.9  Restart home meds when appropriate  Maintain telemetry  Avoid nephrotoxic medications and trend renal function, monitor for fluid overload   11. DVT prophylaxis   Z29.9  Heparin subcu   Orders:   Dextrose 10% in Water 500 mL, Total Volume (mL) = 500, IV, 10/31/22 22:46:00 EDT, PRN - See Comments  glucagon, 1 mg, IM, Injection, Unscheduled, PRN, Hypoglycemia, 10/31/22 22:46:00 EDT  glucose, Per Glucose Level, IV Push, Injection, Unscheduled, PRN, Low Blood Sugar, 10/31/22 22:46:00 EDT  heparin, 5,000 Units, Subcutaneous, Injection, Q8H, Routine, 10/31/22 23:00:00 EDT  insulin lispro, Sliding Scale, Subcutaneous, Injection, With Glucose Testing, PRN, Serum Glucose, 10/31/22 22:46:00 EDT  Lactated Ringers 1,000 mL, Total Volume (mL) = 1,000, IV, 10/31/22 22:46:00 EDT, for 24 Hours, 11/01/22 22:45:00 EDT, 175 mL/hr, Clinical Weight  magnesium sulfate, 2 GM, IVPB, Infusion, Q12H, PRN, Lab (Details Required), 10/31/22 22:45:00 EDT, 25 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 50  magnesium sulfate, 4 GM, IVPB, Infusion, Q12H, PRN, Lab (Details Required), 10/31/22 22:45:00 EDT, 25 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 100  morphine, 2 mg, IV Push, Injection, Q4H, PRN, Pain Severe IV (7-10 out of 10), 10/31/22 22:46:00 EDT  OXYcodone, 5 mg, Orally, Tablet, Q4H, PRN, Pain Moderate PO (4-6 out of 10), 10/31/22 22:46:00 EDT  OXYcodone, 2.5 mg, Orally, Tablet, Q4H, PRN, Pain Mild PO (1-3 out of 10), 10/31/22 22:46:00 EDT  piperacillin-tazobactam, 3.375 GM, IVPB, Injection, Q8H, Indication: Intra-Abdominal Infection, 11/01/22 0:00:00 EDT, 100 mL/hr, Infuse Over 30 minutes, Total Volume (mL) = 50  potassium chloride, 20 mEq, IVPB, Infusion, Unscheduled, PRN, Lab (Details Required), 10/31/22 22:45:00 EDT, 50 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 100  potassium chloride, 20 mEq, IVPB, Infusion, Unscheduled, PRN, Lab (Details Required), 10/31/22 22:45:00 EDT, 50 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 100  potassium chloride, 20 mEq, IVPB, Infusion, Unscheduled, PRN, Lab (Details Required), 10/31/22 22:45:00 EDT, 50 mL/hr, Infuse Over 2 Hours, Total Volume (mL) = 100  sodium phosphate, 21 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 10/31/22 22:45:00 EDT, 50 mL/hr, Infuse Over 3 Hours, Total Volume (mL) = 150  sodium phosphate, 21 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 10/31/22 22:45:00 EDT, 50 mL/hr, Infuse Over 3 Hours, Total Volume (mL) = 150  sodium phosphate, 28 mmol, IVPB, Injection, Unscheduled, PRN, Lab (Details Required), 10/31/22 22:45:00 EDT, 37.5 mL/hr, Infuse Over 4 Hours, Total Volume (mL) = 150  Admit to Inpatient   Auto Diff  Basic Metabolic Panel  Bladder Scan  Blood CX  Blood CX  Call (Specify)  Call Blood Glucose  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  Collect Specimen  Collect Specimen  Collect Specimen  Fall Precautions  Fluid Intake Requirement  Gluc-Strip POC  Hepatic Function Pnl  Initiate IV Care Protocols As Appropriate  Initiate Mobility Protocol  Initiate Skin and Wound Care Protocol  Intake + Output Strict  Level of Care  Lipid Panel SerPl QN  Magnesium SerPl QN  Medical Service  Medication Message to Nursing  Message to Nursing  Message to Nursing  Message to Nursing  Message to Nursing  MRI Cholangiogram MRCP W/O IV Contrast  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Notify Provider  Notify Provider  NPO Except Medications  Nutrition Consult  Peripheral IV Insertion  Phosphorus SerPl QN  Reason for Not Ordering Long-acting Insulin  Resuscitation Status  Sequential Compression Device  Single Oxygen Saturation  Telemetry Class III 24hr Recommendation  TSH w FreeT4 reflex  Vital Signs  Weight  Weight  Zosyn Pharmacy Dosing Consult   Code Status   Resuscitation Status - Ordered    -- 10/31/22 22:46:00 EDT, Full Code   Chronic Problem List    Ankle pain  B12 deficiency  BMI 34.0-34.9,adult  BPH (benign prostatic hyperplasia)  Bursitis of left knee  Controlled type 2 diabetes mellitus  Coronary artery disease  DM (diabetes mellitus), type 2, uncontrolled w/neurologic complication  Encounter for long-term (current) use of medications  HTN (hypertension)  Hyperlipidemia  Hyperlipidemia associated with type 2 diabetes mellitus  Hypokalemia  Hypomagnesemia  Hypothyroidism  OA (osteoarthritis)  Obesity  Peripheral edema  Septic arthritis  Varicose veins of lower extremity  Procedure/Surgical History  ?colonoscopy (07/07/2016) ?H/O coronary artery bypass surgery.. (12/29/2014) ?CABG (Coronary artery bypass grafting) planned ?knee replacement ?Tonsillectomy   Surgical History Internal  07/07/2016    Colonscpy Diagnostic/Screen     MD  Medications   Home Medications (20) Active  acetaminophen 500 mg oral tablet 500 mg = 1 Tablet, PRN, Orally, Q6  albuterol 2.5 mg/3 mL (0.083%) inhalation solution 2.5 mg = 3 mL, PRN, Neb Inhal, Q4H  amLODIPine 10 mg oral tablet 10 mg = 1 Tablet, Orally, Daily  Ascensia Bayer Contour Test Strips Check up to 2 times daily, Other, Unscheduled, Dispense QS 90 daysDx: 250.01  aspirin 81 mg oral tablet, delayed release 81 mg = 1 Tablet, Orally, Daily  carvedilol 6.25 mg oral tablet 6.25 mg = 1 Tablet, Orally, BID  cloNIDine 0.1 mg oral tablet 0.1 mg = 1 Tablet, PRN, Orally, TID  clopidogrel 75 mg oral tablet 75 mg = 1 Tablet, Orally, Daily  DME Compression Stockings Not Applicable, Other, Unscheduled, Dispense 1 pair of stockings; wear as directed.  25mm Hg  DME Compression Stockings Not Applicable, Other, Unscheduled, Dispense 1 pair of stockings; wear as directed.25-30 mmHg below the knees.  Dx:  venous stasis with peripheral edema  Florastor 250 mg oral capsule 250 mg = 1 Capsule, Orally, BID  levothyroxine 50 mCg (0.05 mg) oral tablet 50 mCg = 1 Tablet, Orally, Before Breakfast  Lipitor 40 mg oral tablet 40 mg = 1 Tablet, Orally, Daily  Misc Supplies See Instructions, bilateral below the knee compression stockings. 20-25 mmHg.  diagnoses: Bilateral peripheral edema and venous stasis  Norco 5 mg-325 mg oral tablet 1 Tablet, PRN, Orally, TID  OneTouch Ultra Test Strips Check up to 3 times daily, Other, Unscheduled, DX:E11.9NPI:1659365484  OneTouch Ultra Test Strips See Instructions, CHECK SUGARS BIDDX: E11.9  Potassium Chloride (Eqv-K-Tab) 20 mEq oral tablet, extended release 20 mEq = 1 Tablet, Orally, BID  tamsulosin 0.4 mg oral capsule 0.4 mg = 1 Capsule, Orally, At Bedtime  Viagra 50 mg oral tablet 1-2 Tablet, PRN, Orally, Daily  Active Scheduled Inpatient Medications  heparin (heparin 5,000 units/0.5 mL injectable solution), Injection, 5,000 Units, Subcutaneous, Q8H, Start: 10/31/22 23:00:00  Zosyn, Injection, 3.375 GM, IVPB, Q8H, Indication: Intra-Abdominal Infection, Start: 11/01/22 00:00:00  Lactated Ringers  1,000 mL IV  175 mL/hr 0  11/01/22  Dextrose 10% in Water 500 mL IV PRN - See Comments       One-Time Medications Given 10/31/22 00:00:00 TO 11/01/22 06:49:35  None Reported  PRN Medications (0600 - 0559) from 10/31 - 11/01  OXYcodone, 2.5 mg, Orally, Q4H, 0  Dose(s)   OXYcodone, 5 mg, Orally, Q4H, 1  Dose(s)   glucagon, 1 mg, IM, Unscheduled, 0  Dose(s)   glucose, Per Glucose Level , IV Push, Unscheduled, 0  Dose(s)   insulin lispro, Sliding Scale , Subcutaneous, With Glucose Testing, 0  Dose(s)   magnesium sulfate, 2 GM, IVPB, Q12H, 0  Dose(s)   magnesium sulfate, 4 GM, IVPB, Q12H, 0  Dose(s)   morphine, 2 mg, IV Push, Q4H, 0  Dose(s)   potassium chloride, 20 mEq, IVPB, Unscheduled, 1  Dose(s)   sodium phosphate, 21 mmol, IVPB, Unscheduled, 0  Dose(s)   sodium phosphate, 28 mmol, IVPB, Unscheduled, 0  Dose(s)   Allergies   No Known Medication Allergies  Social History    Alcohol   Denies   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Employment/School   Retired   Home/Environment   Married. 4 children.   Substance Abuse   Denies   Tobacco   Tobacco Use: Former smoker, quit more than 30 days ago.  Family History   DM (diabetes mellitus)..: Mother.  Heart attack..: Mother.  Hypertension..: Mother.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 10.2 k/cumm (11/01/22 03:21:00)  RBC: 3.67 million/cumm Low (11/01/22 03:21:00)  Hgb: 10.8 GM/dL Low (11/01/22 03:21:00)  Hct: 31.6 % Low (11/01/22 03:21:00)  MCV: 86 fL (11/01/22 03:21:00)  MCH: 29.5 pg (11/01/22 03:21:00)  MCHC: 34.3 GM/dL (11/01/22 03:21:00)  RDW: 18.2 % High (11/01/22 03:21:00)  Platelet: 193 k/cumm (11/01/22 03:21:00)  MPV: 7.8 fL (11/01/22 03:21:00)  Neutrophils %: 80 % (11/01/22 03:21:00)  Lymphocytes %: 11 % (11/01/22 03:21:00)  Monocytes %: 8 % (11/01/22 03:21:00)  Eosinophils %: 0 % (11/01/22 03:21:00)  Basophils %: 1 % (11/01/22 03:21:00)  Absolute Neutrophil: 8.1 k/cumm High (11/01/22 03:21:00)  Absolute Lymphocyte: 1.1 k/cumm (11/01/22 03:21:00)  Absolute Monocyte: 0.8 k/cumm (11/01/22 03:21:00)  Absolute Eosinophil: 0.1 k/cumm (11/01/22 03:21:00)  Absolute Basophil: 0.1 k/cumm (11/01/22 03:21:00)  Chemistry:  Sodium SerPl QN: 138 mmol/L (11/01/22 03:21:00)  Potassium SerPl QN: 3.2 mmol/L Low (11/01/22 03:21:00)  Chloride SerPl QN: 105 mmol/L (11/01/22 03:21:00)  Carbon Dioxide SerPl QN: 23 mmol/L (11/01/22 03:21:00)  Anion Gap: 10 mmol/L (11/01/22 03:21:00)  BUN SerPl QN: 21 mg/dL High (11/01/22 03:21:00)  Creatinine SerPl QN: 1.78 mg/dL High (11/01/22 03:21:00)  Estimated GFR (CKD-EPI, no race): 38 mL/min/1.73m2 Low (11/01/22 03:21:00)  Estimated CRCL (CG): 36 mL/min Low (11/01/22 03:21:00)  Glucose SerPl QN: 119 mg/dL High (11/01/22 03:21:00)  Calcium Total SerPl QN: 8.1 mg/dL Low (11/01/22 03:21:00)  Phosphorus SerPl QN: 5.1 mg/dL High (11/01/22 03:21:00)  Alkaline Phos SerPl QN: 264 Units/L High (11/01/22 03:21:00)  ALT SerPl QN: 279 Units/L High (11/01/22 03:21:00)  AST SerPl QN: 183 Units/L High (11/01/22 03:21:00)  Bilirubin Direct SerPl QN: 0.9 mg/dL High (11/01/22 03:21:00)  Bilirubin Total SerPl QN: 2.4 mg/dL High (11/01/22 03:21:00)  Total Protein SerPl QN: 5.1 GM/dL Low (11/01/22 03:21:00)  Albumin SerPl QN: 3 GM/dL Low (11/01/22 03:21:00)  Magnesium SerPl QN: 1.8 mg/dL (11/01/22 03:21:00)  Lipase SerPl QN: 5738 Units/L High (10/31/22 15:38:00)  Troponin-I High Sensitivity: 14 ng/L (10/31/22 15:38:00)  BNP Pl QN: 59 pg/mL (10/31/22 15:38:00)  Lactate Venous Pl QN: 1.1 mmol/L (10/31/22 15:38:00)  Gluc-Strip, POC: 97 mg/dL (11/01/22 06:39:00)  TSH 3rd Gen SerPl QN: 1.83 mcU/mL (11/01/22 03:21:00)  Urine Studies:  Color: Yellow (10/31/22 15:36:00)  Clarity: Clear (10/31/22 15:36:00)  Specific Gravity: 1.010 (10/31/22 15:36:00)  pH: 5.5 (10/31/22 15:36:00)  Protein: NEGATIVE (10/31/22 15:36:00)  Glucose: NEGATIVE (10/31/22 15:36:00)  Ketones: NEGATIVE (10/31/22 15:36:00)  Bilirubin: NEGATIVE (10/31/22 15:36:00)  Hgb Ur: NEGATIVE (10/31/22 15:36:00)  Nitrite: NEGATIVE (10/31/22 15:36:00)  Urobilinogen: NormalUro (10/31/22 15:36:00)  Leukocyte Esterase Ur: NEGATIVE (10/31/22 15:36:00)  All Other Labs:  COVID 19 Specimen Source: Nasal (10/31/22 19:56:00)  Coronavirus SARS-CoV2 Rapid: Not Detected (10/31/22 19:56:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 10/31/2022 16:29 - XR Chest PA or AP  IMPRESSION:Previous open heart surgery.Moderate hiatal hernia as before.No acute cardiopulmonary findings.    10/31/2022 16:55 - US RUQ/Liver/GB/Pancreas  IMPRESSION: Nonvisualization of the pancreas due to overlying bowel gas.Dilated abnormal gallbladder mostly filled with debris withinabnormally thickened wall. Surgical consultation is recommended.Mild common bile duct dilatation, possibly within the range of normalfor a patient of this age.    10/31/2022 17:39 - CT Abd/Pelvis W/IV Contrast  IMPRESSION:1.  Peripancreatic fat stranding compatible with acute interstitialpancreatitis. No peripancreatic fluid collection.2.  Mildly dilated common bile duct extending to the ampulla. Nosignificant intrahepatic biliary dilatation. Cholelithiasis withoutevidence of acute cholecystitis. Consider further evaluation withMRCP.3.  Severe atherosclerosis with infrarenal abdominal aortic aneurysm,diameter 4.9 cm.4.  Additional nonacute and incidental findings as above.Thank you for consulting our team of subspecialty radiologists at hospital. Healthcare providers wishing to discussthis case further can contact the Imaging. For after-hours or emergency department cases.                Signature Line Electronically Signed on 11/01/22 06:50 EDT ________________________________________________________ DO