Date: 11/09/2021
Hospital Visit (Internal medicine)
Identifying data:
Full name: Mr. V
Address: Queens, NY
Date of Birth: 06/19/1958
Location: New York-Presbyterian, Flushing, NY
Religion: non-religious
Source of Information: Self
Reliability: Reliable
Source of Referral: none
Mode of Transport: EMS
Chief Complaint: “I had gall stones” x 3 weeks ago.
History of Presenting Illness:
Patient is a 63-year-old male with PMHx of CABG, HTN, ESRD, who presented to the ED by EMS x 3 weeks ago from his home with complaints of 10/10 of abdominal pain which he points to as being around his lower right abdomen. The patient states he would experience the pain anytime he would eat. He also stated that he would vomit red colored vomitus whenever he tried to eat solid food or drink water. The patient states that it was discovered in the hospital that he was bleeding internally. The patient also complained of nausea during acute episodes of pain. He also complained of constipation during the period he had the abdominal pain. The patient described the pain as constant and felt as though someone “had a knife.” He states that nothing alleviated the pain. The patient denied taking any medication or anything else to relieve the pain prior to arriving at the hospital. The patient however, states that he waited x 1 week from the onset of the abdominal pain before seeking medical care. Patient denied any recent sick contacts, denies any other bowel changes besides constipation, denies any cough, sob, dyspnea, fever, chills, recent travel. The patient states that he had a similar episode of pain 2 months ago, with 10/10 severity. He states that the previous pain was from gall stones but when asked to point to the location of the previous pain he pointed towards his upper left sternal border. The patient however mentioned that during the episode 2 months ago he was given fluids in the hospital, and he eventually passed the stone in the hospital. The patient is covid vaccinated and flu vaccinated. The patient is currently post-op ERCP and is awaiting discharge. He denies any further complaints currently.
Past Medical History:
– HTN x 10-12 years ago
– Umbilical hernia repair – does not remember when
– Polyps x 2 years ago
– ESRD (on dialysis) x 1 year.
– Pneumonia x 1 year ago – was admitted and treated in the same hospital
Past Surgical History:
– Fracture femur x 11 years ago
– CABG x 10 years ago
– Pace maker x 10 years ago. Near the upper left sternal border
– ERCP to remove gall stone x 1 week.
Medications:
– Could not recall medications
– Covid vaccination “few months ago”
– Flu shot “5 months ago”
Allergies:
-Penicillin – states had a reaction but could not recall what type of reaction and when it occurred
-Denies any food and environmental allergies
Family History:
Mother -Lung cancer (was also a smoker)
Father – Aneurysm – did not specify type
Sister – does not know (does not keep in contact)
Son – does not know
Social history:
-Lives alone and was divorced twice
-Retired ever since he had a heart attack x 10 years ago.
-Drinks at home once a week, and 4-5 beers at a time
-Denies any smoking history.
-Denies use of illicit drugs
-Diet is bland due to dialysis and gall stone pain, used to drink 1cup of coffee a day but no longer does
-Denies any sleep disturbances
-Goes on walks often (each day)
Review of system:
General – denies fever and chills
Skin, hair, and nails- denies any recent trauma, denies any discoloration to skin
Head – Denies headache, denies trauma, denies vertigo
Eyes – Denies any recent visual changes. Does not wear corrective lenses
Ears – denies ringing in ears,
Nose /Sinuses – denies rhinorrhea, denies facial pain or pressure, denies epistaxis
Mouth/ throat – denies tonsillectomy, denies tonsilitis, denies ulcers
Neck – denies any pain, denies swelling
Breast – denies any pain or discoloration
Pulmonary system – denies dyspnea, cough, shortness of breath.
Cardiovascular system – denies chest pain or palpitations but points towards left sternal border when giving hx of previous gall stone episode
Abdominal: denies any current abdominal pain, but points to RLQ where surgery was done, and previous pain occurred.
Gastrointestinal system – complained of nausea, red vomitus, constipation, denies any other bowel changes
Genitourinary system – denies dysuria
Menstrual /obstetrical – not applicable
Nervous – Denies generalized weakness or loss of consciousness
Musculoskeletal – denies any muscle/ joint pain
Peripheral vascular system – denies calf pain, swelling of feet
Hematological -denies any recent trauma, denies anemia
Endocrine system – denies nocturia, night sweats
Psychiatric – denies any depression or anxiety
Physical exam:
Vital signs:
L/R (supine): could not perform because patient had fistulas on both arms for dialysis
Pulse: 68 bpm, regular
RR: 16 breaths/min unlabored
T: 96.4F orally
O2 sat: 97% on room air
BMI: Weight: he did not remember; Height: 6 ft
General: Caucasian, male, is alert and oriented to person, place, and time (x3), appears older than stated age, appears in no acute distress
Skin, hair, and nails: good skin turgor, dark purplish discoloration around the fistula sites on both arms, hair is evenly distributed on head and across arms and upper bod. No Jaundice noted. No splinter hemorrhages, clubbing or spoon nails.
Head: No moon facies, acromegaly. No masses or lesions noted on the face. No tenderness to palpation of the head. Hair is brown, not brittle with good distribution. No seborrhea, lice, or mites. No bruising noted.
Eyes: PERRLA. No Icterus, No lacrimation. No periorbital swelling, no strabismus. 20/20 visual acuity.
Ears: No mastoiditis, no swelling and erythema noted around the auricle. No tenderness to palpation of the auricle. No erythema in ear canal. No periauricular sinus. Weber test was normal with sound heard in both ears. Air conduction is greater than bone conduction.
Nose: Patent bilaterally. No external lesions or masses noted. No tenderness to palpation around the maxillary and frontal sinuses.
Neck: No lymphadenopathy noted. Trachea midline. No Goiter. No tenderness to palpation.
Mouth: No central cyanosis around oral region.
Pulmonary: Lungs were clear to auscultation Bilaterally. No wheezing, rales, rhonchi, or stridor.
Cardiovascular: Normal S1 and S2 sounds. No JVD noted. No thrills and heaves.
Abdominal exam: Bowel sounds present in all four quadrants, No pain with light and no pain on deep palpation. No ascites noted. No fluid wave noted. Tympany was noted in all four quadrants.
Breast: Patient was not comfortable having this exam.
Genitourinary: Patient was not comfortable with performing this exam. Patient was not comfortable with a rectal exam
Menstrual and Obstetrical: Does not pertain to the patient
Endocrine system: No excessive sweating, or goiter
Neuro exam: Normal gait, Brachioradialis, Triceps and Biceps reflex 2+ bilaterally. Intact to light touch, sharp/dull, and vibratory sense throughout. No atrophy, tics, tremors, or fasciculation. Cranial nerve 2 and 8 are intact.
Peripheral vascular system: denies intermittent claudication, no varicose vein, +1 peripheral edema bilaterally.
Assessment:
63-year-old male with PMHx of CABG, HTN, ESRD presents to the hospital s/p ERCP for cholecystitis x 1 week ago. Pt is vaccinated for covid and influenza. Pt is in no acute distress at this time and is awaiting discharge.
Differential:
- Cholecystitis: High suspicion due to history of gallstone and RUQ pain, nausea, vomiting with meals as per history. Diagnosis was made and patient is s/p ERCP to remove gall stone.
- Choledocholithiasis: Another consideration for suspicion because of RUQ pain, vomiting and nausea, and history of previous gall stones.
- Polyps flare up: Moderate suspicion based on previous history of polyps and presence of lower abdominal pain
- Gastritis: mild suspicion due to acute onset of complaint of nausea and vomiting of bright red blood which also is influenced by meals.
- Appendicitis: low suspicion because pain is appearing to be in the RUQ but would not r/o since pain is acute and could be poorly localized.
.
Plan:
-Cholecystitis: Patient is post-op from ECRP. Will continue to monitor and place on fluids. Will prepare to discharge in a few days.
