Document Type: History and Physical   Document Subject: History & Physical Note   Performed By: MD on June 06, 2023 13:27 EDT   Verified By: MD on June 06, 2023 16:10 EDT   Encounter Info: Hospital, Emergency, 06/06/23 - 06/06/23    * Final Report *          History of Present Illness/Subjective     Chief complaint: Abdominal pain  Patient is a 59-year-old female history CAD hypertension hypothyroid smoker complains of upper abdominal pain x3 days, constant, dull, radiates to her back, nothing makes it better or worse.  She has tried tylenol and other otc medications without relief. Woken up in the middle of the night w/ cold sweats.  Denies chest pain shortness of breath nausea vomiting or dysuria.  Denies any surgical abdominal history.  States pancreatitis diagnosed a few years ago but was sent home and does not know etiology of her pancreatitis.  Still currently drinks alcoholic beverages 2-3 times a week.   Upon evluation in ER found to have mild pancreatitis without abscess. Present on CT imaging.  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  T: 36.7 °C (Oral)  BP: 148/100  HR: 96 (Monitored)  HR: 97 (Peripheral)  RR: 17  SpO2: 95%  Oxygen Therapy: Room air  WT: 101.20 kg (WFC)   Hemodynamics   Neurologic  Glasgow Coma Score: 15  Patient Weight  Current Daily Weight:    101.2 kg    06/06/23    Patient Height  Current Height:    172.7 cm    06/06/23        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. Pancreatitis   K85.90   Patient has pancreatitis on the imaging at the time of presentation to the emergency room.  -Keep patient n.p.o. start patient on normal saline 125 mill an hour  -Nausea control with Zofran and pain control via Dilaudid and Norco.  -Reintroduce diet tomorrow if patient is doing better.  -Obtain GI consult if needed.  -No need to trend lipase.   2. Upper abdominal pain   R10.10   See problem #1   3. Alcohol abuse   F10.10   Patient is known to have alcohol use disorder.  -Check alcohol levels today and monitor for withdrawal.   4. CAD (coronary artery disease)   I25.10   Noted.  Resume home medications.  Patient is chest pain-free.   5. Hypertension   I10   Resume home medications.  -Withhold lisinopril due to current pancreatitis.   6. Hypothyroidism   E03.9   Resume home medications.    Code Status   None Recorded   Chronic Problem List    Affective disorder  Alcohol abuse  Alcohol intoxication  Allergic rhinitis  Black stools  CAD (coronary artery disease)  CAD in native artery  Cervicalgia  Chronic gastritis  Dyslipidemia  Dyspnea  Hypertension  Hypokalemia  Hypothyroidism  Hypovitaminosis D  Left ankle pain  Low back pain  Lumbosacral Spondylosis without Myelopathy  Osteoarthrosis, Unspecified Whether Generalized or Localized, Involving Other Specified Sites  Polypharmacy  Preventive measure  Rheumatoid Arthritis  Spinal cord stimulator status  Tobacco use  Tobacco use  Procedure/Surgical History  ?Appendectomy ?Ear surgery - rebuilt ear drums ?Hysterectomy ?T & A   Surgical History Internal  07/31/2012    Spinal Drug Pump Revise Remove    MD  06/29/2009    Spinal Drug Pump Revise Remove   MD  Medications   Home Medications (14) Active  albuterol-ipratropium , Neb Inhal  aspirin 81 mg, Orally, Daily  Combivent 103 mcg-18 mcg/inh inhalation aerosol with adapter 2 Puff, Inhalation, Daily  DME Compression Stockings Not Applicable, Other, Unscheduled, Dispense 1 pair of stockings; wear as directed. Above the knee  DME Shower Chair Not Applicable, Other, Unscheduled  GaviLyte-G With Lemon Flavor Pack oral powder for reconstitution See Instructions, as directed.  levothyroxine 25 mCg, Orally, Daily  Lipitor 10 mg, Orally, Daily  lisinopril 2.5 mg oral tablet , TAKE 1 TABLET BY MOUTH ONCE DAILY  Lyrica 75 mg oral capsule 75 mg = 1 Capsule, Orally, TID  Nexium 40 mg oral delayed release capsule 40 mg = 1 Capsule, Orally, BID  oxygen 2 liters  Prenatal Multivitamins 1 Tablet, Orally, Daily  ProAir HFA , PRN, Inhalation  Active Scheduled Inpatient Medications  None Reported    One-Time Medications Given 06/05/23 00:00:00 TO 06/06/23 13:27:48  HYDROmorphone (Dilaudid), Injection, 0.5 mg, IV Push, ONCE, (1 DOSE 06/06/23 10:34:00)  HYDROmorphone (HYDROmorphone Inj ED (1 mg/mL)), Injection, 1 mg, IV Push, ONCE, (1 DOSE 06/06/23 13:16:00)  metoCLOPramide, Injection, 10 mg, IV Push, ONCE, (1 DOSE 06/06/23 12:33:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 06/06/23 09:19:00)  ondansetron, Injection, 4 mg, IV Push, ONCE, (1 DOSE 06/06/23 11:12:00)  Sodium Chloride 0.9% (Sodium Chloride 0.9% - ED Bolus), Infusion, 1,000 mL, IVPB, ONCE, (1 DOSE 06/06/23 12:22:00)  PRN Medications (0600 - 0559) from 06/05 - 06/06  None Reported  Allergies   sulfa drugs  Arthrotec (Numbness)  Darvocet (Nausea)  Effexor ("feels wierd")  Keflex (Rash)  Neurontin (Nausea)  Paxil (Nausea)  Topamax (Nausea)  Ultram (Nausea)  morphine (Hives)  sulfADIAZINE (Rash)  Social History    Alcohol   Current, Liquor, 1-2 times per week   Electronic Cigarette/Vaping   E-Cigarette Use Never.   Substance Abuse - Denies Substance Abuse   Current, Marijuana   Tobacco   Tobacco Use: 10 or more cigarettes (1/2 pack or more)/day in last 30 days.  Family History   Diabetes mellitus: Mother and Sister.  Lab Results    All Labs Last 24 hours (No Micro or Pathology)  Hematology:  WBC: 15 k/cumm High (06/06/23 09:13:00)  RBC: 4.99 million/cumm (06/06/23 09:13:00)  Hgb: 16.6 GM/dL High (06/06/23 09:13:00)  Hct: 48.9 % (06/06/23 09:13:00)  MCV: 98 fL (06/06/23 09:13:00)  MCH: 33.3 pg (06/06/23 09:13:00)  MCHC: 33.9 GM/dL (06/06/23 09:13:00)  RDW: 14.4 % (06/06/23 09:13:00)  Platelet: 244 k/cumm (06/06/23 09:13:00)  MPV: 7.8 fL (06/06/23 09:13:00)  Chemistry:  Sodium SerPl QN: 137 mmol/L (06/06/23 09:13:00)  Potassium SerPl QN: 3.6 mmol/L (06/06/23 09:13:00)  Chloride SerPl QN: 97 mmol/L Low (06/06/23 09:13:00)  Carbon Dioxide SerPl QN: 30 mmol/L High (06/06/23 09:13:00)  Anion Gap: 10 mmol/L (06/06/23 09:13:00)  BUN SerPl QN: 18 mg/dL (06/06/23 09:13:00)  Creatinine SerPl QN: 0.72 mg/dL (06/06/23 09:13:00)  Estimated GFR (CKD-EPI, no race): >90 (06/06/23 09:13:00)  Estimated CRCL (CG): 105 mL/min (06/06/23 09:13:00)  Glucose SerPl QN: 108 mg/dL High (06/06/23 09:13:00)  Calcium Total SerPl QN: 9.1 mg/dL (06/06/23 09:13:00)  Alkaline Phos SerPl QN: 70 Units/L (06/06/23 09:13:00)  ALT SerPl QN: 78 Units/L High (06/06/23 09:13:00)  AST SerPl QN: 66 Units/L High (06/06/23 09:13:00)  Bilirubin Direct SerPl QN: 0.1 mg/dL (06/06/23 09:13:00)  Bilirubin Total SerPl QN: 0.6 mg/dL (06/06/23 09:13:00)  Total Protein SerPl QN: 6.9 GM/dL (06/06/23 09:13:00)  Albumin SerPl QN: 4.1 GM/dL (06/06/23 09:13:00)  Amylase SerPl QN: 69 Units/L (06/06/23 10:44:00)  Lipase SerPl QN: 496 Units/L High (06/06/23 09:13:00)  Troponin-I High Sensitivity: 10 ng/L (06/06/23 09:13:00)  Urine Studies:  Color: Yellow (06/06/23 10:43:00)  Clarity: Clear (06/06/23 10:43:00)  Specific Gravity: 1.026 (06/06/23 10:43:00)  pH: 6.5 (06/06/23 10:43:00)  Protein: 10 Abnormal (06/06/23 10:43:00)  Glucose: Normal (06/06/23 10:43:00)  Ketones: NEGATIVE (06/06/23 10:43:00)  Bilirubin: NEGATIVE (06/06/23 10:43:00)  Hgb Ur: NEGATIVE (06/06/23 10:43:00)  Nitrite: NEGATIVE (06/06/23 10:43:00)  Urobilinogen: Normal (06/06/23 10:43:00)  Leukocyte Esterase Ur: NEGATIVE (06/06/23 10:43:00)  WBC: 0-5 (06/06/23 10:43:00)  RBC: 0-2 (06/06/23 10:43:00)  Bacteria: NONE (06/06/23 10:43:00)  Squamous Epithelial: Few (06/06/23 10:43:00)    Diagnostics  Radiology Results - Last 24 hours Across Visits 06/06/2023 10:19 - XR Chest PA or AP Portable  IMPRESSION:Cervical spine stimulator.No acute findings.    06/06/2023 11:51 - CT Abd/Pelvis W/IV Contrast  IMPRESSION: Diffuse hepatic steatosis.Subtle inflammation around the head of the pancreas and descendingportion of the duodenum may represent mild pancreatitis versusduodenitis. Correlate clinically.Status post hysterectomy.Retained spine stimulator electrode.                Signature Line Electronically Signed on 06/06/23 16:10 EDT ________________________________________________________ MD