|A general surgery hospital "consult" for abdominal pain...
THIS IS A MEDICARE PATIENT so a consult would be billed as an initial hospital visit.
REASON FOR CONSULTATION: Abdominal pain and abnormal CT scan.
HISTORY OF PRESENT ILLNESS: Patient is 48-year-old female admitted on September 22, 2010 for coagulopathy and abdominal pain. The patient states she was doing okay at home and was told to come to the hospital due to an elevated INR. On further questioning, she states she has had some abdominal discomfort radiating to the back associated with nausea and vomiting. She states this happens periodically and has not anything significantly different than what she experienced chronically over several years. She has known gastroparesis and history of congestive heart failure. She has been felt to have a passive venous hepatic congestion and mesenteric congestion causing her abdominal pain secondary to congestive heart failure. She has had diagnosis of gastroparesis as well. She is on Reglan for this and she also takes Prilosec and Pepcid for peptic ulcer disease. For further evaluation on this admission of her abdominal pain, she had a noncontrast CT renal colic of the abdomen, which showed some inflammation around the porta hepatis. She is status post cholecystectomy. She has had no recent significant alcohol use and her amylase and lipase on admission were normal. The surgery service was asked to evaluate her abdominal pain and these inflammatory changes in the region of the cholecystectomy bed and head of the pancreas.
PAST MEDICAL HISTORY: Remarkable for congestive heart failure, ischemic cardiomyopathy, atrial fibrillation, coronary artery disease, cardiorenal syndrome, renal failure, valvular heart disease, CVA, heparin-induced thrombocytopenia, anemia, pulmonary embolus, COPD, hypertension, hyperlipidemia, and morbid obesity.
PAST SURGICAL HISTORY: Includes coronary bypass, mitral valve replacement, pacemaker, hysterectomy, maze procedure, cholecystectomy, and right salpingo-oophorectomy.
ALLERGIES: HEPARIN, PENICILLIN, KEFLEX, AND SULFA.
12. At home, she is also on Coumadin.
SOCIAL HISTORY: Living independently at home. No recent smoking and denies alcohol use.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: She has no current dizziness or syncope. She has no current chest pain, and mild shortness of breath on exertion. Abdominal pain as discussed. Denies any changes in stool habits. She denies any melena, hematochezia. She states her emesis has been light green. No blood has been noted. She has no dysuria or hematuria.
GENERAL: Obese black female in no significant distress. She is ambulating comfortably in the room. VITAL SIGNS: HR in the 70s, BP 115/75, T 96.9.
SKIN: No jaundice or skin lesions.
CHEST: The breasts are symmetric and pendulous. No palpable masses.
HEART: Regular with a systolic murmur.
LUNGS: Breath sounds diminished at the bases, midline scar noted.
ABDOMEN: Obese, scarred in several locations. There is tenderness in the epigastric region, slight tenderness in the right upper quadrant. No rebound, no guarding. No significant lower abdominal tenderness. No obvious hernias. Rectal: No masses, heme negative.
EXTREMITIES: Nontender. No significant edema. Pulses are diminished.
LABORATORY DATA: White count 5.5, H&H 10.3 and 32.7, and platelet count 135,000. INR is 8.05. PT of 71, on admission INR was 12.8, potassium is 5.2, BUN and creatinine are 53 and 3.8. The liver function test showed mildly elevated alkaline phosphatase 140. Transaminases are normal. Amylase and lipase on September 22, 2010 were normal at 72 and 212. The BNP level was 19, 388.
CT scan of the abdomen was reviewed and was limited by lack of contrast. There does appear to be some streaky changes in the region of the gallbladder fossa and around the pancreatic head and porta hepatis. No abscesses visualized. There is no biliary dilatation, appears to be a stable 2 cm proximally calcified nodular structure in the anterior margin of the right lobe of the liver. There is no renal calculi or hydronephrosis. No pneumoperitoneum or sigmoid diverticulosis, small amount of pelvic ascites and an obvious diverticulitis. Echo report shows EF of only 15 -20%.
IMPRESSION: Abdominal pain of uncertain etiology. The patient has frequent episodes of abdominal pain with multiple possible contributing factors. Gastroparesis and gastritis likely accounts for her recurrent episodes of nausea and vomiting. Peptic ulcer disease may also account for the inflammation around the pancreatic head and duodenum. There is no elevation of the amylase and lipase, however, the pancreatitis is in the differential. The patient's liver function tests are normal. The patient is status post cholecystectomy and I do not think this is related to the biliary system. The patient's ascending colon and transverse colon in this region were appeared to be normal. I agree with EGD for further evaluation. Continue PPI therapy. Continue Reglan for gastroparesis. There is no obvious surgical illness at this time. Recommend observation. I will repeat her liver function profile and amylase and lipase in the a.m. to assess for any interval changes. The patient was informed of the plan of management in brief.
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