H&P #3

H&P #3

 Chief Complaint: 

“I feel nauseous with really bad stomach pain”x 5 days 

History of Present Illness:(01/23/2024)

81 y/o female with a PMH of Hypertension,HLD, GERD, and Osteoporosis presents to the ED from home for LLQ abdominal pain for 5 days.Pt reports constant LLQ pain 10/10 in severity that does not radiate. Pain worsens when palpated deeply and is unrelieved by Advil 400mg q6h .Pt reports going to urgent care on the 20th  due to a similar episode of pain and was discharged with ciprofloxacin and instruction to go to the ER if symptoms worsened. Pt admits to not taking prescribed ciprofloxacin with the same LLQ pain worsening, prompting her to return to the ED. Patient also endorses associated nausea and 2 episodes of nonbilious, non bloody vomiting without changes in bowel movements.Pt denies any fever, diarrhea, constipation, blood in stool or previous history of similar event. 

Past Medical History:

Hypertension (unknown location of Dx by PCP, unknown year) 

GERD (unknown location of Dx by PCP, unknown year)

Osteoporosis(unknown location of diagnosis by unknown provider unknown year) 

Past Surgical History:

  • Partial R Hip replacement(walker for 3 months post op but needs no assistance now) 

Medications:(Before Admission)

Lovastatin(unknown dosage, unknown frequency, PO, daily for hypercholesterolemia)

Omeprazole (unknown dosage, unknown frequency, PO, daily for GERD)

Caltrate(unknown dosage)

Unknown HTN medication for BP

Denies consumption of other supplements, herbal, or prescribed/OTC medications.

Medications: (Post Admission) 

Acetaminophen 975 mg, Oral, every 6 hours scheduled 2145(first dose 01/23/24) for 30 days, for pain relief 

Pantoprazole enteric coated tablet 40 mg oral daily 0900(first dose 01/24/2024) for 60 days , for GERD symptoms

Piperacillin- tazobactam 4500 mg in 100 mL D5W, administer over 4 hours, every 8 hour(first dose 01/30/24) for 7 days, per ID consult 

Pravastatin 20mg, Oral, bedtime, (first dose  01/24/2024) for 60 days, for HLD  

Nifedipine 30 Mg oral at 2100 (first dose 01/29/2024) for 54 doses, due to rising BP in with systolic BP in the 150s on  01/28/24

Hold parameter:SBP<110

Allergies:

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

Family History:

  • Father- Died at 64 due MI (unknown medical history)
  • Mother- Died at 97d/t unknown cause (unknown medical history)

Social History:

  • M.G is a 81 y/o F who is retired, living with her husband in a co-op apartment in Regal Park, NY. 
  • Habits – Pt occasionally drinks(once a week),denies smoking and illicit drug use
  • Travel – no recent travel 
  • Diet – “normal balanced diet”. As per patient, she “eats a little bit of everything”.
  • Exercise – Walk a “couple blocks occasionally” (once or twice a week) . ADLs/IADLs intact and fully independent. Keeps cane at home due to osteoporosis dx, never needed its use.
  • Sleep – Admits normal sleep cycle. Sleeps 7-8 hours daily. 
  • Safety measures – practices seatbelt safety measures
  • Ancillary Physician- Dr. Norman Regal(cardiologist), Unknown PCP.

Review of Systems:(01/31/2024)

  • General: Admits to generalized fatigue (reports due to currently on liquid diet as cause), fever, chills, night sweats, weight loss or gain, changes in appetite.
  • Skin, hair, nails: Denies discolorations, pigmentations, moles/rashes, changes in hair distribution or texture, pruritus.
  • Head: Denies headaches, head trauma, 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: Denies chest pain, edema/swelling of ankles or feet, syncope, palpitations, or known heart murmur.
  • Gastrointestinal: Admits to mild LLQ pain with palpation . Denies,diarrhea  constipation, decreased flatulence. Denies, 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.
  • 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:Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD.

 Physical Exam:(01/31): Nurse present during PE (nurse name not noted)

Vitals:

  • BP: 134/78(supine)
  • HR:  85(regular)
  • RR: 20 (unlabored)
  • T: 36.6 C (oral)
  • O2: 96% (room air)

General: Patient appears clean & well groomed, alert & oriented to time, place, and person. Has good posture and appears to be a reliable source of information. Appears stated age and is not in acute distress.

Skin: Warm & moist; non-icteric; no rashes or lesions. 

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

Eyes: Sclera white, cornea clear, conjunctiva pink. 

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 nontender 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. No rales, rhonchi or wheezing

Abdomen:LLQ tenderness upon palpation with palpable fullness to the same. Round, no distention, no striae or pulsations noted. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. No guarding or rebound noted. No hepatosplenomegaly to palpation.

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

Reflexes: Intact, 2+ brachioradialis, triceps, biceps, patellar, Achilles reflexes bilaterally.
Absent Babinski. No clonus.

Peripheral Vascular: The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in brachial, radial, DP and PT arteries. No bruits noted, clubbing, cyanosis, edema, stasis changes, or ulcerations bilaterally.

Female GU exam: Freely voiding, other wise not exposed

Differential Diagnosis:

  • Diverticulitis with organized fluid collection 
  • IBD
  • Nephrolithiasis 

Workup: 

  • Labs:
 Latest Reference Range & Units01/30/24 101/31/24
WBC COUNT (include numbers in presentation) 4.80 – 10.80 x10(3)/uL16.80(H)17.69
HEMOGLOBIN11.7 – 15.3 g/dL11.511.7
HEMATOCRIT35.0 – 45.0 %34.134.6
MEAN CORPUSCULAR VOL (MCV)78.0 – 100.0 fL86.385.6
MEAN CORP HGB (MCH)26.0 – 34.0 pg29.129.0
MEAN CORP HGB CONC (MCHC)31.0 – 37.0 g/dL33.733.8
RED CELL DIST WIDTH (RDW)11.5 – 14.5 %15.815.9
RED BLOOD CELL COUNT4.50 – 5.20 x10(6)/uL3.954.04
NUCLEATED RBC AUTO0.00 – 0.00 /100 WBC’s0.000.00
NUCLEATED RBC ABSOLUTE0.00 – 0.00 x10(3)/uL0.000.00
PLATELET COUNT, AUTO150 – 400 x10(3)/uL416448
MEAN PLATELET VOLUME, AUTO8.0 – 11.0 fL8.99.2
NEUTROPHILS %, AUTO37.0 – 80.0 %73.480.3
NEUTROPHILS, ABSOLUTE, AUTO1.80 – 8.50 x10(3)/uL12.32 14.21
LYMPHOCYTES %, AUTO15.00 – 40.00 %11.80 6.60
LYMPHOCYTES, ABSOLUTE, AUTO0.80 – 3.50 x10(3)/uL1.991.17
MONOCYTES %, AUTO3.0 – 10.0 %11.510.6
MONOCYTES, ABSOLUTE, AUTO0.20 – 0.90 x10(3)/uL1.941.88
EOSINOPHILS %, AUTO0.00 – 5.00 %0.700.70
EOSINOPHILS, ABSOLUTE, AUTO0.00 – 0.60 x10(3)/uL0.120.12
BASOPHILS %, AUTO0.00 – 1.00 %0.300.40
BASOPHILS ABSOLUTE, AUTO0.00 – 0.30 x10(3)/uL0.050.07
IMMATURE GRANULOCYTES %0.00 – 1.00 %2.301.40
IMMATURE GRANULOCYTES, ABSOLUTE0.00 – 0.10 x10(3)/uL0.380.24

 		Latest Reference Range & Units01/30/24 01/31/2024
Sodium135-145141137
Potassium3.5-53.54.1
Chloride95-105103100
Carbon Dixoxide23-292725
BUN6-246.96.8
BUN/Creatinine 10:1-20:11413
Creatinine0.7-1.30.480.54
Glucose70-100110112
Anion Gap10-161112
Calcium, total 8.5-10.58.18.2

Imaging

01/24 CTAP: 3.5 cm collection in deep anterior abdominal wall in left lower quadrant likely localized perforation and early abscess formation secondary to diverticulitis. Left hydro, lingular 6 mm nodular opacity likely benign/postinflammatory, gallstones, small RT renal cyst, atherosclerosis, small umbilical hernia, possible appendicolith but -appendicitis. 

01/30 Repeat CT: interval increase in size of left lower quadrant peridiverticular abscess, now measuring 6.0 x 4.5 cm. Near complete resolution of hydronephrosis 

Impression:

Assessment:

81 y/o HD 8 admitted for Hinchey 1B diverticulitis with 3.5cm abscess anterior to descending sigmoid junction. PPD 6 s/p percutaneous drainage of intraabdominal abscess.Wound cultures positive for pan-susceptible Pseudomonas aeruginosa and E. coli,on zosyn . Pt afebrile w/ WBC count elevated for past 4 days, prompting a repeat CT today, showing an increase in size of LLQ peridiverticular abscess, now measuring 6.0 x 4.5 cm.

Pt today was in no acute distress, only stating LLQ pain upon palpation which has been better than previous days. PT denies any nausea,vomiting or changes in stool.

Plan:

  1. Intraabdominal abscess
    1. Continue Zosyn, administered over 4 hours, every 8 hours for 7 days.
    2. Switch to modified Fiber diet(until specified), IVF(LR 1,000 Intravenous, once)
    3. NPO @Midnight 
    4. IR drainage of intraabdominal abscess
    5. Plan for admission to surgical unit post op, 
    6. F/U morning CBC(monitor Wbc Count)
    7. ID consult for home infusion update(Line placement once WBX downtrends)
  2. HTN
    1. Continue home meds
  3. BUN
    1. Repeat BMP(monitor kidney function)
  4. DVT
    1. Prophylaxis with Lovenox 40 mg subcutaneous, midnight