Identification:

Patient’s name: Mrs. X

DOB: 31 years old

Gender: Female

Race: Asian

Location: NYPQ, Flushing, NY

Date and Time: 9/24/2019, 10am

Informant: self, reliable

CC:  periumbilical abdominal pain x 1 day

HPI: A 31 years old female with a past medical history of HTN and anemia c/o sudden onset of periumbilical abdominal pain starting yesterday at 2pm. Pain is described as crampy, consistent, 5/10 severity without radiation. The patient endorses nausea and 2 episodes of non-bloody, non-bilious emesis, and she also reports passing gas and last bowel movement was yesterday morning and was watery. The patient denies fever, chills, appetite changes, constipation or any other symptoms. In the ED, the patient is afebrile and hemodynamically stable. Laboratory studies are within normal limits. CT scan performed in the ED which was significant for small bowel obstruction with a transition point in the mid ileum, for which general surgery is consulted.

PMH:

HTN x 6 years

Anemia x 15s years

Past Surgical History:

C-section July 2019

Medications:

Current facility administrated medications:

Labetalol 200mg PO QD

FeSO4 325mg PO BID

Home medications:

Labetalol 200mg PO QD

FeSO4 325mg PO BID

Allergies:

Patient denies any drugs, foods, or environment allergies.

Family History:

Grandfather- 70s, deceased, CVD, HTN

Grandmother- 70s, deceased, DM

Father- 62, HTN, goat

Mother- 57, HLD

Son- 2 months, alive and well

Social History:

Mrs. X lives with her husband and son in Queens. She is a banker, and her sleep quality is very good, and she usually sleeps about 8 hours a day. No exercise, and she has a large coffee every morning. Sexually active, monoamory, no history of STDs. Denies recent travel, alcohol consumptions, tobacco use, past or present illicit drug use.

ROS:

General: Patient denies recent weight loss or weight gain, fatigue, loss of appetite, generalized weakness, fever, chills, or night sweats

Skin, Hair, Nails: Patient denies any changes of texture, excessive dryness or sweating, discolorations, rashes

Head: Patient denies headache, vertigo, head trauma, or fracture

Eyes: Patient denies visual disturbance, lacrimation, pain, or pruritus

Ears: Patient denies deafness, pain, discharge, tinnitus

Nose/Sinuses: Patient denies discharge, or obstruction

Mouth and throat: Patient denies bleeding gums, sore tongue, sore throat

Neck: Patient denies localized swelling or lumps, stiffness or decreased range of motion

Pulmonary System: Patient denies SOB, cough, denies hemoptysis, cyanosis, or orthopnea

Cardiovascular System: Patient denies chest pain, palpitations, edema, syncope

Gastrointestinal System: Patient reports periumbilical abdominal pain, nausea, vomit, denies dysphagia, diarrhea, jaundice, hemorrhoids, constipation, blood in stool

Genitourinary System: Patient denies nocturia, urgency, oliguria, polyuria, dysuria

Nervous System: Patient denies headache, loss of consciousness, sensory disturbances, numbness, paresthesia, loss of strength, mental status, memory, or weakness

Musculoskeletal System: Patient denies deformity or swelling, or redness

Peripheral System: patient denies intermittent claudication, varicose veins

Hematological System: Patient denies anemia, easy bruising or bleeding

Endocrine System: Patient denies polyuria, polydipsia, polyphagia, heat or cold intolerance

Psychiatric: Patient denies depression, or anxiety

Physical Examination:

General: 31 years old female is alert and oriented x3, medium build, in patient’s gowns, lying in stretcher, in no acute distress

Vital Signs:

BP (lying): 133/86

HR: 84 BMP, regular

RR: 16

Temp: 36.8 oral

O2 sat: 98% room air

Height: 5ft 1in weight: 124.6 lbs BMI: 23.5, normal

Skin: Warm & moist, good turgor

Hair: Average quantity and distribution

Nails: No clubbing, capillary refill <2 seconds throughout.

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: PERRLA, EOMs full with no nystagmus, exophthalmos or ptosis; sclera white; conjunctiva & cornea clear. Visual acuity 20/20 OS, 20/20 OD, 20/20 OU. Visual fields full OU

Ears: Symmetrical and normal size. No lesions, masses, trauma on external ears. No discharge. TM’s pearly white, cone of light intact, small amount of cerumen noted bilaterally

Nose: Symmetrical with no masses, lesions, deformities, or trauma

Throat: Pink, hydrated, no lesions, uvula light pink, no edema

Neck: Trachea midline. Supple nontender to palpation. No lymphadenopathy

Chest: Symmetrical, no deformities. Nontender to palpation

Lungs: Breath sounds heard bilaterally. No rales, no wheezing, no rhonchi

Heart: RRR, S1, S2 without murmur, no gallops

Abdomen: Soft, mildly distended, mild periumbilical tenderness. No rebound, no guarding, no CVA tenderness bilaterally

Rectal: patient refused

Female genitalia: patient refused

Peripheral vascular: No cyanosis or edema bilaterally, 2+ pulses in upper and lower extremities

Neurological:  Alert and oriented to person, place and time. Memory and attention intact. Thought coherent. Intact to light touch, sharp/dull. No focal deficit

Cranial nerve:

I – not exanimated.

II- VA 20/20 bilaterally with glasses. Visual fields full.

III-IV-VI- pupils equal, round, and react to light, EOM intact without nystagmus.

V- Facial sensation intact.

VII- Symmetric facial movements, no weakness.

VIII- Hearing grossly intact to whispered voice bilaterally.

IX-X-XII- Swallowing intact. Tongue movement intact.

XI- Shoulder shrug intact. Sternocleidomastoid and trapezius muscle strong.

Musculoskeletal System: No soft tissue swelling, erythema, ecchymosis. Nontender to palpation, no crepitus noted throughout. Full active and passive ROM of all extremities

Differential Diagnosis:

• Small bowel obstruction
• Paralytic ileus
• Colonic obstruction
• Acute gastroenteritis
• Acute appendicitis
• Acute pancreatitis
• Acute mesenteric ischemia
• Postoperative ileus
• Esophageal tear/rupture
• Inflammatory bowel disease
• Ovarian torsion

Labs:

UA: clear, PH 6.5, negative for glucose, protein, ketones, nitrite, leukocyte esterase

 

143 | 105| 15.7

——————–< 120

4.5 |  24| 1.00

 

10.7

7.29)——-(347, neutrophil: 75.5%; Lymphocyte 15.3%; Monocyte 5.5%

34.2

Prot: 6.0/Alb: 3.4/Bili: 0.5/AST 13/AlkPhos: 82/Lip:27

Imaging:

CT of the abdomen: Small bowel obstruction with a transition point in the mid ileum in the anterior pelvis. The ileal loops distal to the transition point appear thick-walled and hyperemic, extending to the ileocecal junction

Assessment: A 31 years old female with a past medical history of HTN and anemia c/o sudden onset of periumbilical abdominal pain starting yesterday afternoon. Pain is crampy, consistent, 5/10 severity without radiation. Also, nausea and 2 episodes of non-bloody, non-bilious emesis, passing gas and last bowel movement was yesterday morning and was watery. Denies fever, chills, appetite changes, constipation or any other symptoms. In the ED, the patient is afebrile and hemodynamically stable. On physical examination, mildly distended abdomen and mild tenderness over the periumbilical area. Laboratory studies are within normal limits. CT scan performed in the ED which was significant for small bowel obstruction with a transition point in the mid ileum. Current findings are most consistent with small bowel obstruction.

Plan:

• Small bowel obstruction
  • Admit to general surgery
  • NPO/IVF (LR 125cc/hr)
  • If pain worsen or begins having nausea/vomiting, will consider NG tube placement
  • Encourage out of bed
  • Monitor bowel function
• HTN
  • Continue home medications, Labetalol 200mg PO QD
  • Monitor BP

• Anemia
  • Continue home medication FeSO4 325mg PO BID
  • Trend H&H

• Diet :
  • NPO

• Follow up appointments
  • Patient need follow up appointment with PCP within 1 week after anticipated discharge if not appointment already scheduled