CHIEF COMPLAINT: High blood pressure.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female who has been recently admitted for pneumonia. The patient was actually just discharged yesterday. She has been at home and not feeling well.
She started to have some vomiting and has noticed that her blood pressure has been high. She continues to feel nauseated and not well and now here for evaluation.
The patient denies any diarrhea; in fact, she has been constipated. She has not had a bowel movement for 7 or 8 days. She denies any abdominal pain however.
PAST MEDICAL HISTORY: Significant for thyroid surgery. The patient has arthritis in her back and on home oxygen since her discharge yesterday at 6 liters.
CURRENT MEDICATIONS: Amlodipine, prednisone, thyroid medication, albuterol.
ALLERGIES: None.
SOCIAL HISTORY: The patient lives with a companion who accompanies her here today. She has smoked in the past but has quit. She occasionally drinks alcohol.
REVIEW OF SYSTEMS: Unremarkable for fever. The patient feels no shortness of breath, no cough. She denies abdominal pain but does have nausea and vomiting as well as constipation. She has had swelling in bilateral legs. This has been going on for years. She said normally the swelling is worse in the right than on the left. She has tried different medications for this, which have not seemed to work. The swelling is not any worse than usual at this time. The patient has no dysuria, and she denies any other system complaints at this time.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 36.3, heart rate 102, respiratory rate 22, blood pressure in the right arm 166/92, in the left arm 154/78, 02 sat 93% on 6 liters nasal cannula.
GENERAL: The patient is awake, alert, oriented, in no obvious distress, speaking long full sentences.
SKIN: Warm and dry with no rash.
HEENT: Pupils reveal some postoperative changes, mostly on the left. The right pupil is reactive. Pharynx with moist mucous membranes.
NECK: Supple, nontender with no JVD.
LUNGS: Respirations are clear and equal bilaterally with no wheezes, rales or rhonchi.
HEART: There is a regular rate and rhythm, although slightly tachycardiac initially.
ABDOMEN: The abdomen is soft and nontender. There is minimal distention, but there is no pain with deep palpation, no focal tenderness, no mass.
EXTREMITIES: The patient is moving all extremities with minimal edema of the bilateral lower extremities and no deformities or tenderness.
NEUROLOGIC: Intact sensation distally.
IMPRESSION: The patient may have continued pneumonia causing her to feel unwell. My main concern at this time is her nausea and vomiting. She has not had a bowel movement for the last 7-8 days. I am concerned that she may have severe constipation or obstipation, and she may have an ileus or bowel obstruction causing her to have these problems.
The patient did have some vomiting upon admission last time and it was felt to be probable viral illness, but she has since started to vomit again and my concern is for bowel obstruction or ileus. As far as the high blood pressure is concerned, the patient’s main concern today was the high blood pressure, but her blood pressures in the emergency room have not been terribly high.
DIAGNOSTIC/LAB STUDIES: Chest x-ray revealed an ill-defined opacity in the left lower lobe as well as some small bilateral pleural effusion. Abdominal x-ray reveals findings suggestive of an early small bowel obstruction or ileus.
Lipase is high at 756. Comprehensive metabolic panel reveals sodium of 135, BUN is high at 35, but creatinine 1.1, ALT high at 238, and AST of 114. Magnesium is normal. Troponin less than 0.02, CBC with a white count of 13.2, normal hemoglobin and hematocrit and platelets.
EKG interpretation by ER physician reveals a sinus rhythm of a ventricular rate of 98. There are non specific ST-T wave changes, but no acute injury pattern is noted.
EMERGENCY ROOM COURSE: IV was started. The patient was placed on a monitor and oxygen to keep her oxygen saturations greater than 90%. On about 5 liters, the patient is able to remain with oxygen saturations in the low 90s.
She remains relatively comfortable in the ER while she is here, except she does have some vomiting, so she was given Zofran 4 mg IV to help with this, and her vomiting was controlled after she was given the Zofran.
The patient has signs of a possible early bowel obstruction and is vomiting. We felt the patient should stay in the hospital for further evaluation until this resolves. We discussed the case with Dr. John Doe, who is covering for the patient’s primary care physician. He accepted the patient to the hospital for further care. The patient was comfortable with the plan, and was stable on transfer to the medical floor under the care of Dr. John Doe.
DIAGNOSIS: Ileus and vomiting, elevated liver enzymes and pancreatitis.
PLAN: Admission to the medical floor under the care of Dr. John Doe.
