Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: Gen Med Consult - 51
Description: Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction. The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission.
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is an 89-year-old white male who developed lower abdominal pain, which was constant, onset approximately half an hour after dinner on the evening prior to admission. He described the pain as 8/10 in severity and the intensity varied. The symptoms persisted and he subsequently developed nausea and vomiting at 3 a.m. in the morning of admission. The patient vomited twice and he states that he did note a temporary decrease in pain following his vomiting. The patient was brought to the emergency room approximately 4 a.m. and evaluation including the CT scan, which revealed dilated loops of bowel without obvious obstruction. The patient was subsequently admitted for possible obstruction. The patient does have a history of previous small bowel obstruction approximately 20 times all but 2 required hospitalization, but all resolved with conservative measures (IV fluid, NG tube decompression, bowel rest.) He has had previous abdominal surgeries including colon resection for colon CA and cholecystectomy as well as appendectomy.
PAST HISTORY: Hypertension treated with Cozaar 100 mg daily and Norvasc 10 mg daily. Esophageal reflux treated with Nexium 40 mg daily. Allergic rhinitis treated with Allegra 180 mg daily. Sleep disturbances, depression and anxiety treated with Paxil 25 mg daily, Advair 10 mg nightly and Ativan 1 mg nightly. Glaucoma treated with Xalatan drops. History of chronic bronchitis with no smoking history for which he uses p.r.n. Flovent and Serevent.
PREVIOUS SURGERIES: Partial colon resection of colon carcinoma in 1961 with no recurrence, cholecystectomy 10 years ago, appendectomy, and glaucoma surgery.
FAMILY HISTORY: Father died at age 85 of "old age," mother died at age 89 of "old age." Brother died at age 92 of old age, 2 brothers died in their 70s of Parkinson disease. Son is at age 58 and has a history of hypertension, hypercholesterolemia, rheumatoid arthritis, and glaucoma.
SOCIAL HISTORY: The patient is widowed and a retired engineer. He denies cigarettes smoking or alcohol intake.
REVIEW OF SYSTEMS: Denies fevers or weight loss. HEENT: Denies headaches, visual abnormality, decreased hearing, tinnitus, rhinorrhea, epistaxis or sore throat. Neck: Denies neck stiffness, no pain or masses in the neck. Respiratory: Denies cough, sputum production, hemoptysis, wheezing or shortness of breath. Cardiovascular: Denies chest pain, angina pectoris, DOE, PND, orthopnea, edema or palpitation. Gastrointestinal: See history of the present illness. Urinary: Denies dysuria, frequency, urgency or hematuria. Neuro: Denies seizure, syncope, incoordination, hemiparesis or paresthesias.
GENERAL: The patient is a well-developed, well-nourished elderly white male who is currently in no acute distress after receiving analgesics.
HEENT: Atraumatic, normocephalic. Eyes, EOMs full, PERRLA. Fundi benign. TMs normal. Nose clear. Throat benign.
NECK: Supple with no adenopathy. Carotid upstrokes normal with no bruits. Thyroid is not enlarged.
LUNGS: Clear to percussion and auscultation.
HEART: Regular rate, normal S1 and S2 with no murmurs or gallops. PMI is nondisplaced.
ABDOMEN: Mildly distended with mild diffuse tenderness. There is no rebound or guarding. Bowel sounds are hypoactive.
EXTREMITIES: No cyanosis, clubbing or edema. Pulses are strong and intact throughout.
GENITALIA: Atrophic male, no scrotal masses or tenderness. Testicles are atrophic. No hernia is noted.
RECTAL: Unremarkable, prostate was not enlarged and there were no nodules or tenderness.
LAB DATA: WBC 12.1, hemoglobin and hematocrit 16.9/52.1, platelets 277,000. Sodium 137, potassium 3.9, chloride 100, bicarbonate 26, BUN 27, creatinine 1.4, glucose 157, amylase 103, lipase 44. Alkaline phosphatase, AST and ALT are all normal. UA is negative.
Abdomen and pelvic CT showed mild stomach distention with multiple fluid-filled loops of bowel, no obvious obstruction noted.
1. Abdominal pain, nausea and vomiting, rule out recurrent small bowel obstruction.
3. Esophageal reflux.
4. Allergic rhinitis.
PLAN: The patient is admitted to the medical floor. He has been kept NPO and will be given IV fluids. He will also be given antiemetic medications with Zofran and an analgesic as necessary. General surgery consultation was obtained. Abdominal series x-ray will be done.
Keywords: consult - history and phy., abdominal pain, nausea, vomiting, small bowel obstruction, nausea and vomiting, colon resection, allergic rhinitis, bowel obstruction, hypertension, glaucoma, benign, obstruction,