SUBJECTIVE: The patient continues to have significant abdominal pain as well as back pain. She states that the pain is about a 7/10 currently and is located just below and lateral to her umbilicus and the previous scar site. She complains of lumbar burning back pain as well. The patient denies chest pain but does feel that she is short of breath. She states that she feels like there is “fluid in her lungs.”
OBJECTIVE:
VITAL SIGNS: Temperature is 98.2, heart rate 68, blood pressure 134/62, respiratory 18, O2 sat 97% on room air.
GENERAL: The patient is awake but slightly drowsy. No acute distress. She is oriented. She has slight increased work of breathing.
CHEST: Clear to auscultation bilaterally. There is no wheeze or crackle.
HEART: Regular rate and rhythm. Normal S1, S2.
ABDOMEN: Soft. There is tenderness to palpation and a small hernia that is inferior to and lateral to the umbilicus that is reducible. Positive bowel sounds.
EXTREMITIES: The patient has tenderness to palpation in the lumbar region and upper back on either side of her spine. There is no lower extremity edema. Upper and lower extremity pulses are equal and regular.
LABORATORY DATA: WBC 12.2, down from 15.2 yesterday. Hemoglobin is 7.8 (the patient’s baseline hemoglobin is 7.8-9.4), hematocrit 23.2, platelets 301. Hemoglobin A1c 5.4. Glucose 115, BUN 44, creatinine 3.8, sodium 134, potassium 4.2, chloride 108, bicarbonate 14, calcium 8.9. ABG: PH of 7.2, pO2 92, bicarb 15, O2 saturation 97% on 4 L nasal cannula. Troponins are negative x2. Urinalysis demonstrates 2+ leukocyte esterase, 10-19 wbc’s and occasional bacteria.
CT scan of the abdomen and pelvis without contrast was negative for acute findings. Chest x-ray is negative for acute findings.
ASSESSMENT AND PLAN: The patient is a (XX)-year-old female with:
1. Abdominal pain and flank pain: The patient does appear to have a possible UTI and has been started on IV ciprofloxacin for this. She continues to complain of severe abdominal pain and back pain. Given her extensive surgical history, including abdominal aortic aneurysm repair and renal artery and left iliac grafting as well as metabolic acidosis, I did discuss the case with Vascular Surgery, who will come evaluate the patient. She also has a ventral hernia and this will be evaluated also. I have ordered an ultrasound of the patient’s aorta for further evaluation. Lactic acid is 0.9. I will repeat the ABG and lactate in a few hours. Lipase was negative and leukocytosis does seem to be improving. The patient’s hemoglobin is 8.2; however, this is similar to her baseline. We will continue monitoring with serial H&Hs. The patient does have a history of GI hemorrhage and a Dieulafoy lesion. She will be admitted to the medicine team for further evaluation and management of the above issues. Unfortunately, CT with contrast cannot be performed due to the patient’s chronic renal failure.
2. Chest pain: The patient’s cardiac enzymes are negative. The patient’s EKG showed normal sinus rhythm, normal axis, poor R-wave progression, no significant ST-T wave changes. Her pain seems more epigastric in nature. Continue IV Protonix.
3. Stage IV chronic kidney disease: The patient’s creatinine is at her baseline.
4. Hypertension: Continue lisinopril and labetalol.
5. Hyperlipidemia: Continue pravastatin.
6. History of Dieulafoy lesion, noted on EGD on MM/DD/YYYY. Continue the present management and monitoring H&H, status post cauterization and sclerotherapy at that time.
7. Ongoing tobacco abuse: The patient has been counseled for more than 10 minutes regarding cessation.
8. Prophylaxis: PCDs.
