Primary Care Provider: DR A
Accompanied by: Spouse
Visit Type: Acute Visit
Chief Complaint: f/u ED -continued rectal bleeding and belching
History of Present Illness:
Patient is a Years Old _ who presents for severe pain s/p umbilical hernia repair 2 days ago. Last night he/she began to have severe abdominal pain. He/She started having blood in his/her stool and went to the ER last night. He/She was sent home. WBC slightly elvated at 13.6 and Creatinine slightly increased at 1.47. He/She has a decreased appetite but has been able to tolerate liquids and solids without vomit. He/She has some severe abdominal pain and nauseated. He/She noticed incfeased urinary frequency which is clear/yellow color.
ER records reviewed which had a normal rectal exam.
Mild constipation from being on hydrocdone.
Problem List Changes:
Added new problem of Body mass index (BMI) 38.0-38.9, adult (ICD-V85.38) (ICD10-Z68.38) – Signed
Added new problem of Hematochezia (ICD-578.1) (ICD10-K92.1) – Signed
Added new problem of Other acute postprocedural pain (ICD-338.18) (ICD10-G89.18) – Signed
Added new problem of Abdominal pain, acute (ICD-789.00) (ICD10-R10.9) – Signed
Removed problem of Abdominal pain, acute (ICD-789.00) (ICD10-R10.9) – Signed
Added new problem of Abdominal pain, acute (ICD-789.00) (ICD10-R10.9) – Signed
Added new problem of Acute nontraumatic kidney injury (ICD-584.9) (ICD10-N17.9)
Assessed Abdominal pain, acute as new – Signed
Assessed Other acute postprocedural pain as deteriorated – Signed
Assessed Hematochezia as unchanged – Signed
Assessed Acute nontraumatic kidney injury as new
Assessed Abdominal pain, acute as unchanged
Medication List: (Reviewed and Updated)
IBUPROFEN 800 MG ORAL TABLET (IBUPROFEN) 1 po tid
MONTELUKAST SOD 10 MG TAB 10 TAB (MONTELUKAST SODIUM) TAKE ONE TABLET BY MOUTH DAILY
ZYRTEC ALLERGY 10 MG ORAL TABLET (CETIRIZINE HCL) 1 po qd
AVAPRO 300 MG ORAL TABLET (IRBESARTAN) 1 po qd
NORVASC 5 MG ORAL TABLET (AMLODIPINE BESYLATE) 1-2 po qd
ALDACTONE 25 MG ORAL TABLET (SPIRONOLACTONE) 1 po qd
CHLORTHALIDONE 25 MG ORAL TABLET (CHLORTHALIDONE) 1 po qd
TESTOSTERONE CYPIONATE 200 MG/ML INTRAMUSCULAR SOLUTION (TESTOSTERONE CYPIONATE) INJECT 2CC INTRAMUSCULARLY EVERY 2 WEEKS
YALE DISP NEEDLES 22G X 1-1/2" MISC (NEEDLE (DISP)) use as directed with Testosterone given IM q 2weeks
SYRINGE DISPOSABLE 3 ML (SYRINGE (DISPOSABLE)) use as directed with Testosterone IM q 2 weeks
BD DISP NEEDLES 18G X 1-1/2" (NEEDLE (DISP)) use as directed, use to draw up Testosterone give IM q 2weeks
Allergy List: (Reviewed and Updated)
No known allergies
Medical History: (Reviewed and Updated)
hypogonadism
traumatic brain injury
benign essential hypertension
onchmycosis
Sleep apnea
renal insuficency
allergic rhinitis
Surgical History: (Reviewed and Updated)
inguinal hernia
Nasla septum surgery
Social History: (Reviewed and Updated)
married with two children both boys.
Patient has never smoked.
Alcohol Use – yes
Drug Use – no
Regular Exercise – yes
Family History: (Reviewed and Updated)
aunt dementia
father type 2 diabetes
father hypertension
mother obese
Risk Factors:
Tobacco: (Reviewed and Updated)
Review of Systems:
COMPLAINS OF FEVER, CHILLS. All other systems reviewed and are negative
General: COMPLAINS OF FEVER, CHILLS.
Cardio: Denies chest pain, palpitations.
Respiratory: Denies SOB, cough.
GI: COMPLAINS OF ABDOMINAL PAIN, NAUSEA, CONSTIPATION, BLOOD IN STOOLS. Denies vomiting, diarrhea.
Vital Signs:
Weight: 274.2 lbs. (124.64 Kg.) Height: 71 in. (180.34 cm.) BMI: 38.38
Temperature: 97.6 deg F. (36.4 deg C.) Temperature Site: Temporal Pulse: 88 Pulse Rhythm: Regular
Blood Pressure #1: 138/88 mm Hg. Location: Rt Arm Position: sitting
Entered by:
Physical Exam:
General: Well developed, well groomed, in no acute distress.
Head: Normocephalic/atraumatic.
Eyes: PERRL, EOMI; conjunctiva and sclera clear.
Nose: No deformity/significant septal deviation; Normal mucosa.
Mouth: Mucus membranes moist; No erythema / exudates.
Neck: Supple; No thyromegaly or nodules.
Lungs: Clear to auscultation bilaterally.
Cardio: RRR; Normal S1, S2; Without murmurs, gallops, rub, or click.
Abdomen: severe periumbilical pain with guarding/ neg rebound
well healing periumbilical incision with some subcutaneous eccymosis
No masses
No hepatosplenomegaly
+BS
Extremity: No cyanosis or edema.
Skin: No rashes or atypical lesions.
Psych: Alert and oriented.
Assessment and Plan:
ABDOMINAL PAIN, ACUTE (ICD-789.00) (ICD10-R10.9) Unchanged
concern for hematochezia s/p abdominal surgery. intra-op report reviewed which showed no acute complication.
recommend stat CT abd/pelvis (just approved with insurance). sent to radiology for labs and CT scan
OTHER ACUTE POSTPROCEDURAL PAIN (ICD-338.18) (ICD10-G89.18) Deteriorated
pain worse than expected.
HEMATOCHEZIA (ICD-578.1) (ICD10-K92.1) Unchanged
blood in stool is concerning.
pt had colonoscopy 2016 unremarkable except for a small sessile polyp
ACUTE NONTRAUMATIC KIDNEY INJURY (ICD-584.9) (ICD10-N17.9) New
recheck bmp
Medication List Changes:
Removed medication of MOBIC 15 MG ORAL TABLET (MELOXICAM) 1 po qd; Route: ORAL – Signed
Removed medication of MELOXICAM 15 MG TABS (MELOXICAM) TAKE ONE TABLET BY MOUTH DAILY – Signed