Identifying Data:
Full Name: Ms. TB
Address: Astoria, NY
Date of Birth: February 18th, 1948
Date & Time: October 26th, 2020
Location: Metropolitan Hospital
Religion: Catholic
Source of Information: Self
Source of Referral: Self
Mode of Transport: Self
Chief Complaint: “I have abdominal pain” x 1 day.
HPI:
72-year-old female with PMHx of cervical cancer, HTN/HLD, hypothyroidism, urinary incontinence and osteoporosis presents today with abdominal pain that’s started yesterday morning. She describes the pain as crampy abdominal pain which does not radiate anywhere else and when asked where the pain is located, she points on her left lower quadrat area. Pain is constant throughout the day, and patient rates it a 6/10 on the severity scale. After every meal, pain gets worse and patient also reports one episode of vomiting which occurred last night after having dinner. There was no blood in the vomit but was mostly just food she had consumed. Patient also complains of constipation. On average patient reports 4-5 bowel movements a day, however since yesterday she reports no bowel movement but she is able to pass gas (flatus). Patient denies fever, chills, diarrhea, rectal bleeding, heart burn, wheezing, chest pain, shortness of breath, change in appetite, syncope, jaundice, hemorrhoids, nausea, dysuria, or blood in urine.
DDX:
1) Small/Large bowel obstruction (most likely)
2) Diverticulitis
3) Ulcerative Colitis
4) Irritable bowel syndrome
5) COVID-19
Past Medical History:
Past/ Present illnesses – Cervical cancer at age 30; HTN x 10 years; hypothyroidism x 8 years; urinary incontinence x 5 years; osteoporosis x 11 years.
Hospitalizations: Age 30 she had a total hysterectomy due to cervical cancer and was hospitalized for 2 days. She was also hospitalized for 2 days for undergoing total left knee replacement.
Immunizations- Up to date.
Screening tests and results- colonoscopy done in 2016- benign.
Past Surgical History:
Hysterectomy in 1978 with no complications. Does not remember where it was done or the name of the surgeon.
Total left knee replacement in 2015 with no complications. Was done at NYPQ but does not remember the name of the surgeon.
Medications:
Valsartan 80 mg orally once a day, last dose 1 days ago, for HTN.
Lovastatin 20 mg orally once a day, last done yesterday morning for HLD.
Vitamin D (Ergocalciferol) 15 mcg/day PO, last done last night for osteoporosis.
Allergies:
Denies drug, environmental or food allergies.
Family History:
Denies family history of cardiovascular diseases, colon cancer, strokes.
Social History:
Ms. TB denies smoking, alcohol, or illicit drug use.
Currently lives with her daughter and her daughter’s husband in an apartment in Astoria. She does not follow a specific diet and does not exercise regularly however she does walk 2-3 times a week about 2 miles to the nearby park.
Travel- Has not recently traveled anywhere.
Sexual Hx- Not sexually active. No past history of STD’s, HIV, or any other sexually transmitted diseases.
Review of Systems:
General: Denies loss of appetite, fatigue, fever, recent weight gain or night sweats.
Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, or changes in hair distribution.
Head – Denies vertigo or head trauma, or headaches
Eyes – Denies lacrimation, pruritis, visual disturbances, or photophobia. Last eye exam 2018 – does not know her visual acuity, normal pressure.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat –Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes, jaw soreness. Last dental exam 2020.
Neck– Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – Denies lumps, nipple discharge, or pain.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Denies chest pain, palpitations, edema/swelling of ankles/feet, syncope, known heart murmur.
Gastrointestinal system – Complains of crampy left lower quadrant pain x 1 day. Also complains of 1 episode of vomiting and constipation x 1 day.
Genitourinary system – Denies nocturia, urinary frequency or urgency, oliguria, polyuria, dysuria, incontinence.
Nervous – Denies seizures, headaches, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status.
Musculoskeletal system – Complains of some left knee pain that’s worse in the morning. Denies other muscle/joint pain, deformity or swelling, or redness.
Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies mood changes, dementia, depression. Denies sadness, OCD.
Physical exam:
General: Pt is alert and oriented x3, neatly groomed, appears of stated age and in slight distress due to abdominal pain.
Vital Signs: BP: 133/79
R: 18/min unlabored P: 98, regular
T: 97.9 degrees F (oral) O2 Sat: 96% Room air
Height 5’5’’ Weight 152 lbs. BMI: 25.3 (overweight)
Skin: warm to the touch & moist, good turgor. Nonicteric, no lesions noted, no scars, no tattoos.
Head: Head is normocephalic, atraumatic.
Ears: Symmetrical and normal size. EOMs intact, PERRL. No conjunctival injection. No scleral icterus.
Nose – Symmetrical / no obvious masses / lesions / deformities / trauma / discharge. Nasal mucosa pink & appears dehydrated.
Oropharynx –no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pinkish, no edema, lesions.
Neck – Trachea midline. No masses; lesions; scars; pulsations noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally.
Thyroid –Non-tender; no palpable masses; no bruits noted.
Chest/Lungs:
Symmetrical without deformity or signs of trauma. Respiration unlabored and without use of accessory muscles. Non-tender to palpation. Clear to auscultation bilaterally with no adventitious lung sounds.
Heart: Regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: Soft and slightly distended abdomen. Periumbilical and left lower quadrant tenderness to palpation. Hypoactive bowel sounds especially in right and left lower quadrants. No rebound or guarding. No caput medusae or abnormal pulsations. No masses noted.
Peripheral Vascular:
The extremities are normal in color, size, and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally. No ulcerations noted.
Upper & Lower Extremities:
No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Female genitalia: Hysterectomy.
Labs:
-WBC: 9.08 (4.80-10.80)
-HGB: 13.3 (11.7-15.3)
-HCT: 35.8 (35.0- 45.0)
-MCV: 86.7 (78-100.0)
-PLT: 276 (150-400)
-Neutrophil: 66 (37.0-80)
-Lipase: 110 (60-160)
-Lactate: 0.9 (0.5-1.5)
-AST: 27 (5-32)
-ALT: 35 (5-33)
– BUN/Creatinine: 23 (10-20) (dehydration)?
Imaging:
CT abdomen (10/26/2020): dilated small bowel loop and transition zone noted suggesting partial small bowel obstruction.
Assessment: Ms. TB is a 72-year-old female with PMHx of cervical cancer, HTN/HLD, hypothyroidism, urinary incontinence and osteoporosis presented today with LLQ abdominal pain. Physical exam shows slight abdomen distention with periumbilical and LLQ tenderness on palpation and hypoactive bowel sounds in the left and right lower quadrants. CT of the abdomen shows dilated small bowel loop and transition zone suggesting partial small bowel obstruction. Pt is hemodynamically stable.
Plan:
1) NPO to rest bowel and start IV fluids.
2) NG tube for bowel decompression
3) General surgery consult for possible surgical intervention.
4) Monitor I&Os and vital signs.
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