H&P #1

H&P #1

 Chief Complaint: 

As per pt, “my PCP did not ‘clear me’ and referred me here.”

History of Present Illness:

Pt is an 81 year old female with PMHx of HTN, chronic kidney disease, perforated appendicitis and nephrostomy tube placement (August 2023) referred to ER by her PCP due to abnormal lab results. Collateral information was provided by pt’s daughter. She confirms that her mother is undergoing expectant management for her perforated appendicitis since August 2023. Since then pt has been confused and not been acting like herself. She also states that over the past week pt appears to be declining and has been weak, unable to ambulate on her own and refuses to eat solids or drink fluids. Denies fever, chills, n/v, dysuria, cough, shortness of breath and chest pain.

As per ED, pt had a hgb of 6.8 and received transfusion.  

Past Medical History:

  • Hypertension x unknown years, well controlled on medication
  • Chronic Kidney Disease x unknown years
  • R hydronephrosis x unknown years
  • Perforated appendicitis x 08/17/2023, finished IV abx on 12/14 and PICC line removed on 12/15/2023.

Past Surgical History:

  • Nephrostomy placement (August 2023)

Medications:(Before Admission)

  • Amlodipine 10 mg, twice daily
  • Isosorbide Mononitrate 60 mg extended release oral daily
  • Chlorhexidine Gluconate  4% Liquid  as need

Allergies:

  • No known drug allergies
  • No known food allergies
  • No known environmental allergies

Family History:

  • No known significant family history

Social History:

  • Non-Smoker
  • Substance use: Denies alcohol use. Denies drug use.
  • Home situation:Currently lives with her daughter due to need of assistance, regularly lives with husband in apartment 

Review of Systems:

  • General: Admits to weight loss(20 pounds last 6 month span), decreased appetite and generalized weakness/fatigue. Denies fever, chills, night sweats.
  • Skin, hair, nails: Denies discolorations, pigmentations, moles/rashes, changes in hair distribution or texture, pruritus.
  • Head: , vertigo.
  • Eyes: Denies vision loss ,eyelid swelling, pruritus, photophobia, lacrimation.
  • Ears: Denies ear pain, deafness, discharge, tinnitus.
  • Nose: Denies epistaxis, discharge, congestion
  • Mouth/throat: Denies sore throat, voice changes, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies cough, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Admits to history of HTN. Denies chest pain, edema/swelling of ankles or feet, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Denies vomiting,diarrhea  constipation, abdominal pain, decreased flatulence. Denies intolerance to specific foods, dysphagia, pyrosis, diarrhea, jaundice, hemorrhoids, rectal bleeding, hematochezia, melena, hematemesis.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
  • Sexual History: Not currently sexually active. Denies history of STIs.
  • Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
  • Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
  • Hematologic: Anemic, denies easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD.

 Physical Exam:

Vitals:

  • BP: 118/78 (supine)
  • HR: 112 (regular)
  • RR: 16 (unlabored)
  • T: 36.7 C (oral)
  • O2: 98% (room air)
  • Height: 150cm    Weight: 51. kg BMI: 25.84

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Skin: Warm & moist; non-icteric; no rashes some lesions noted on ***

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

Eyes: Sclera white, cornea clear, conjunctiva pink. PERRLA. Visual fields full OU. EOM intact, no nystagmus.

Ears: No lesions, trauma, discharge noted to external ear.

Nose: Symmetrical. Nares patent bilaterally, nasal mucosa pink.

Sinus: Non-tender to palpation.

Mouth/pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and non-tender to palpation. No cervical lymphadenopathy noted.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation bilaterally.

Abdomen: Abdomen is mildly distended and soft. Bowel sounds normoactive in all four quadrants. Nontender, no guarding or rebound noted. No palpable masses. Incision sites healing well 

Peripheral vascular: 2+ pitting edema bilaterally in lower extremities. Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis.

Musculoskeletal: FROM (full range of motion) of all upper and lower extremities bilaterally. Non tender to palpation.

Female GU exam: exam not performed.

Rectal: exam not performed.

Differential Diagnosis:

  • Intra abdominal abscess secondary to perforated appendix
  • Cecal mass
  • Rectosigmoid mass
  • Ovarian tumor
  • Ovarian cyst

Workup: 

  • Labs:
Urinalysis w/ Reflex culture12/29
Urine colorYellow
Urine appearanceClear
Urine glucoseNegative
Urine bilirubinNegative
Urine ketonesNegative
Urine specific gravity1.011
Urine bloodTrace*
Urine pH7.5
Urine proteinTrace*
Urine urobilinogen0.2
Urine nitriteNegative
Urine leukocyte esteraseSmall*
Urine WBC13*
Urine RBC5*
Urine bacteriaNegative
Urine squamous epithelial cells4
Urine hyaline casts1
CBC w/ diff(12/28)
RBC2.46*
HGB6.8*
CRIT21.1*
MCV85.8
MCH27.6
MCHC32.2
RDW20.1*
PLT356
MPV9.2
NEUTP87.1*
LYMPHP8.3*
2MONOP3.6
EOSP0.10
BASOP0.20
NEUT10.76*
LYMPH1.02
MONO0.45
EOS0.01
BASO0.09
BMP(12/28)
NA137
K5.1
CL105
CO223
BUN20.5
CREATININE1.81*
GLU116*
ANION GAP9
CA8.9*
Coags(12/28)
PT11.3
APTT30.2
INR0.98
LFTs(12/28)
TP5.3*
ALB2.6*
GLOB2.7
TBILI0.3
DBILI0.1
IBILIUnable to calc
SGOT41*
AGPT9
ALK131*
Pro-BNP49

Imaging

  1. CT abdomen/pelvis w/o IV contrast
    1. Impression: Right lower quadrant 7 cm collection possibly slightly increased from 6 cm and is inseparable from the adjacent bowel (appendix and terminal ileum), right iliopsoas and right adnexa.
    2. New b/l small pleural effusion. Peri bronchial consolidation in the right middle lobe may represent aspiration. PNA could also be considered in approval rate clinical setting
    3. Subcutaneous thinking in the dependent aspect of b/l femoral greater trochanter may reflect early decubitus ulcer. 

      2. Chest Radiograph(AP)-

      2.No radiographic evidence of pulmonary consolidation 

Preop Diagnosis: 

Abscess secondary to perforated Appendicitis 

Assessment:

81 year old female with recent perforated appendix presents with abnormal lab values. Pt is afebrile and hemodynamically stable s/p transfusion. On exam bilateral pitting edema is noted, with no bruising or bleeding found. On CT abdomen a 7 cm intra abdominal mass that is inseparable from the appendix, terminal ileum and R psoas muscle was discovered.

Plan:

Anemia 

  • CBC following transfusion
  • Orthostatic vital signs
  • Iron studies, folate and B12 
  • Stool guaiac

AKI

  • IV fluids and recheck

Intra abdominal mass

  • Schedule laparoscopic drainage of abscess with possible appendectomy, possible ileocecectomy, possible ostomy.  

Acute Metabolic encephalopathy 

  • Start on antibiotics(CTX) and follow up urine culture. Trend WBC and temp

DVT/GI prophylaxis