Talia Bardash

Surgery H &P

HISTORY  

Identifying Data: 

Full Name: CM

Address: New York, NY 

Date of Birth: 02/02/1954

Date and Time: 01/25/21

Location: Metropolitan Hospital  

Sex: Male 

Age: 67

Race: Hispanic  

Religion: None  

Marital Status: SIngle

Source of Information: Self  

Reliability: Reliable  

Source of Referral: Self 

Chief Complaint: “I have pain in my stomach” x4 days  

HPI: CM is a 67 y/o male with PMH of HTN, T2DM, acute pancreatitis, alcohol abuse  who presents to the ED with a 3 day history of worsening epigastric pain. The pain is characterized by the patient as constant and sharp and rated an 8/10. He states that the pain radiates to his back. Patient states that the pain began as an achy pain and has slowly progressed to a sharp pain. Patient reports that on the first day he took alka-seltzer to try to relieve the pain, which provided moderate relief. On the second day, the patient states that he developed nausea and non-bloody bilious vomiting.  The patient states that the vomiting could fill two full cups.  Patient again took alka seltzer, with no improvement of the symptoms. Patient has not taken any other medication for symptom relief. Patient states that it is worse at night while he is lying down in bed. Patient states that a few years prior he was treated at Lenox Hill for similar symptoms. Patient has struggled with alcoholism and states that Lenox hill discharged him and he was instructed to reduce his alcohol intake. Patient states that he used to drink one bottle of rum a week. Patient reports that he currently drinks two bottles of rum per month. Patient admits to loss of appetite due to the nausea. Patient denies chest pain, shortness of breath, fever or chills. Patient also denies diarrhea, constipation, dystrophy, weakness, numbness, parenthesis, headache, syncope, recent travel, sick contacts or previous abdominal surgeries.   

Past Medical History 

PMH – HTN, acute pancreatitis, T2DM, alcohol abuse 

Immunizations – Patient is up to date on vaccines. Patient has not had his COVID booster and is eligible for the vaccine. 

Screening Tests and Results – 

Colonoscopy: Colonoscopy was not documented but patient states that he had a colonoscopy 2 years prior and they found a benign polyp. 

Past Surgical History 

Denies 

Medications 

Metformin 500 mg PO daily

Allergies 

No known drug, food, or seasonal allergies.  

Family History 

Denies any known family history of cardiovascular disease, abdominal cancers

Social History 

Pt is a 67 y/o hispanic male who lives in New York City. Patient denies having any pets. Patient states that he is sexually active with only females and always uses proper protection. Patient does not use any illicit drugs. Patient states that he is a chronic alcohol drinker. Patient used to drink at least one bottle of rum once a week. He has reduced this number of drinks to two bottles of rum twice a month. 

Habits – Patient does not smoke. 

Travel – Denies any recent travel or sick contacts.  

Diet – Patient enjoys fast food and spicy food.  

Exercise – Patient is not active. 

Sleep – He sleeps an average 5-6 hours/night. 

Review of Systems 

General – Admits to loss of appetite due to the nausea. Denies any fatigue, generalized weakness, unintentional weight loss, fever, chills, sweats, 

Skin, Peripheral Vascular – Denies changes in skin texture/temperature, ulcerations, discolorations, rashes, erythema, or pruritus. Denies intermittent claudication, pallor, paresthesia, numbness/tingling, or edema.  

Head & Neck – Denies any headaches, dizziness, lightheadedness, LOC, or head trauma. Denies visual disturbances, photophobia, sore throat, neck stiffness/mass. 

Pulmonary – Denies SOB, cough, hemoptysis, wheezing, or hx of COPD/asthma. 

Cardiovascular – Admits to history of HTN. Denies chest pain, syncope, or edema. Denies history of arrhythmia, heart murmur, or CAD.   

GI – Admits to vomiting, nausea and abdominal pain. Patient admits to loss of appetite. Denies diarrhea, constipation, rectal bleeding, blood in the stool. Patient denies dysphagia, eructation or any allergies or sensitivities to food.

GU – Denies urinary frequency or urgency, oliguria, polyuria, dysuria, flank pain, or hx of BPH. 

MSK – Denies any pain in joints or muscles or history of arthritis.

Hematological – Denies easy bruising or bleeding, lymph node enlargement, blood transfusions, or hx of DVT/PE or anemia.  

Endocrine – Denies polyuria, polydipsia, polyphagia, heat/cold intolerance, excessive sweating, goiter, or hx of DM or thyroid disease. 

Psychiatric – Denies depression/sadness, anxiety, agitation, or ever seeing a mental health professional  

Neurological – Denies any changes in memory/cognition, weakness, abnormal or uncontrollable movement, unsteady gait, or LOC. 

PHYSICAL  

General – Well-developed male, well-groomed with poor hygiene, mild posture, looks older than his stated age, no difficulty ambulating.  The patient is sitting upright in ER bed, he is A/O x 3, in acute distress. 

Vital Signs- 

BP: 149/63 

Temp: 97.8 degree F

Resp: 17 

Ht: 5’6”

Wt: 190 lbs

SpO2: 99% 

BMI: 30.67 

Skin:

Skin was warm, smooth, mild turgor, nonicteric, no lesions, masses, scars, tattoos, thicknesses or opacities.

HEENT

Atraumatic, normocephalic. No tenderness or pain on the frontal, temporal, occipital, or parietal areas. No deformities or specific faces noted. Patient is balding and hair was very coarse. Unable to assess proper eye exam due to distress of the patient. Mucous membranes are pink; well hydrated. No masses or lesions noted. Non-tender to palpation. No leukoplakia. Oropharynx is well hydrated; no injection, exudate, masses, lesions, foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions. 

Heart

Normal rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. No JVD. Carotid pulses are 2+ bilaterally without bruits.

Lungs

Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus throughout. No adventitious sounds. 

Abdomen

Bowel sounds are normal in all four quadrants. Abdomen is soft. Abdominal tenderness diffusely. Guarding noted. There is no right or left CVA tenderness. Positive Murphy’s sign. NO ecchymosis noted on the skin. Patient is actively vomiting upon evaluation. 

Vascular

2+ peripheral pulses. No edema, clubbing, cyanosis, or ulcerations. Full ROM, muscle strength 5/5 

Psych 

A/O x 3, no agitation.  

Neuro  

No focal deficits, no gait abnormalities. GCS eye subscore is 4. GCS verbal subscore is 5. GCS motor subscore is 6.

LABS 

WBC – 19.72

HGB – 18.6

HCT- 54.3 

Total Bilirubin- 1.9 

AlkPhos -169

ALT – 398

AST- 343

Lactate- 3.9

Troponin – <0.010

FS- 203 

IMAGING/TESTS:

CT ABDOMEN PELVIS WITH OMNIPAQUE 

Severe acute pancreatitis with area of diminished parenchymal enhancement in the tail and body of the pancreas concerning pancreatic necrosis. 

US ABDOMEN: Distal pancreatic body and tail obscured by bowel gas; remaining pancreas appears mildly and diffusely enlarged demonstrating heterogeneous increased echogenicity, consistent with edema/ acute pancreatitis. No common bile duct dilatation; common bile duct resolution not adequate to exclude choledocholithiasis. Hepatomegaly 

EKG: Normal Sinus Rhythm 

DIFFERENTIAL DIAGNOSIS 

1. Alcoholic Pancreatitis  – Patient is presenting with onset of RUQ pain that is confirmed via CT scan and ultrasound. Patient has nausea and vomiting. Patient has had similar episode and was previously diagnosed with alcoholic pancreatic. Patient is a chronic alcohol user. Patient has tenderness to palpation over the abdomen and guarding. Patient has high whtie count, high LDH, high AST, high GLucose, and is above the age of 55 making his Ranson score a 5. Patient unable to lie down properly due to the pain. 
2. MI – Patient is experiencing the pain in the epigastric area. Patient is vomiting. Patient has history of uncontrolled hypertension. Patient is an alcoholic user. 
3. Cholecystitis – Patient has RUQ pain and positive Murphy’s sign.  Patient vomiting due to the pain. Patient unlikely to have cholecystitis due to lack of gallstone in the US of abdomen. 
4. Acute Abdominal Aneurysm- Patient has abdominal pain and tenderness to palpation. Patient is vomiting. Patient is above the age of 65X. 
5. Cholangitis– Pain in the RUQ and vomiting. Tenderness to palpation over the abdomen  Unlikely due to the lack of jaundice and fever. 

DIAGNOSIS: Acute pancreatitis, due to alcohol use.

ASSESSMENT 

67 y/o male with PMH of HTN, T2DM, acute pancreatitis, alcohol abuse  who presents to the ED with a 3 day history of worsening epigastric pain. Lab results and imaging most consistent with a diagnosis of acute alcoholic pancreatitis. 

PROBLEM LIST/PLAN 

1. Admit to Surgery Team for severe acute pancreatitis based on Ranson’s criteria.

1. Patient is a 5 
2. Perform serial abdominal exams q12hs 
3. Diet – NPO except for meds 
4. IV fluids – LR 1000 mg 125-150 ml/hr IV continuous infusion @ 1
5. Pain control – Acetaminophen, Morphine PRN 
6. RUQ US
7. Ondansetron for nausea
8. VTE prophylaxis : heparin SQ injection, 5,000 Units, Subcutaneous, Q8H SCH

3.   EKG to evaluate for arrhythmias or cardiac ischemia 

4. UA to assess for UTI, proteinuria, hematuria

5. Alcohol History – Provide the patient with education about the risks of alcohol use. Provide the patient with a peer counselor that can discuss ways to stop drinking alcohol.  

6. Educate the  patient where to go for COVID booster vaccine when discharged from hospital. 

NEXT DAY FOLLOW UP: 

S: Patient was observed at bedside. No acute overnight events. Pt states his pain has improved from yesterday. Denies nausea, vomiting, fever, chills. Foley in place.

BP: 138/104

RESP: 26

PO2: 92%

Medications:

1. heparin SQ injection, 5,000 Units, Subcutaneous, Q8H SCH
2. insulin detemir, 5 Units, Subcutaneous, Nightly
3. insulin regular, 4-12 Units, Subcutaneous, Before meals & at bedtime
4. meropenem, 1,000 mg, IV Infusion, Q8H SCH
5. pantoprazole, 40 mg, Intravenous, Q24H SCH
6. thiamine, 100 mg, IV Infusion, Daily
7.  Fentanyl prn 
8. Naloxone prn
9. Ondansetron prn 

LABS 

1. WBC: 25.38
2. HGB:19.2
3. HCT: 56.2
4. PLt: 139
5. ALT- 167
6. AST- 69
7. TBilli- 1.5

IMAGING: 

1/21 CXR: IMPRESSION:

Hypoventilatory changes with bibasilar pulmonary opacities which may reflect

atelectasis, aspiration or pneumonia.  

ASSESSMENT AND PLAN: 

67 y/o M with PMH of T2DM and HTN (not controlled on medication) admitted for acute pancreatitis. 

Neuro – patient is alert. For acute pain: fentanyl PCA

Pulm – supplemental O2 PRN, CXR due to decreased O2 stat (results above) 

CV- Monitor vitals

GI- acute pancreatitis: Bilirubin and liver aminases improving, likely ETOH etiology. NPO

Fluids – cont LR @100

GU- foley remains in place, strict I’s and O’s

ID- leukocytosis, possible infected pancreatitis. Start Merrem

Heme – SQH, SCDs

Ppx- SQH

Endo- DM on Metformin at home Insulin sliding scale. Night time Levemir added, sugars >200

MSK- OOB ambulate