DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
CHIEF COMPLAINT: Abdominal pain of one day’s duration.
PRINCIPAL DIAGNOSIS: Abdominal pain, etiology unclear.
OTHER DIAGNOSES:
1. Hypertensive heart disease.
2. Coronary artery disease.
3. Ischemic cardiomyopathy.
4. Congestive heart failure.
5. Acute gouty arthritis.
6. Renal insufficiency.
7. Hyperlipidemia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male with history of hypertension, coronary artery disease status post CABG, required stenting, who was discharged home yesterday after being admitted to telemetry for chest pain. MI was ruled out by serial cardiac enzymes. He presents to the emergency room with complaints of abdominal pain, pointing to the epigastric and right upper quadrant region, of one day’s duration, described as spasms to aching in nature, associated with some nausea, but he denied any vomiting, melena or diarrhea. He denied radiation of the pain, and he had not tried any over-the-counter pain medications.
PAST MEDICAL HISTORY: Significant for ischemic cardiomyopathy, congestive heart failure, history of nonsustained ventricular tachycardia status post AICD placement, hyperlipidemia, gout, and renal insufficiency. His previous hospitalization was for nonsustained ventricular tachycardia.
ALLERGIES: He has no known allergies.
MEDICATIONS AT HOME: Vasotec, Coreg, Lasix, K-Dur, Plavix, and Zocor.
SOCIAL HISTORY: The patient denies smoking, alcohol or any illicit drug use. He lives with his wife.
FAMILY HISTORY: Both parents are deceased. He had one sister who is also deceased, cause is unknown.
PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure 144/82, respiratory rate 16, pulse rate 80, and temperature 101.6. GENERAL APPEARANCE: This is a well-developed male, lying in bed, in mild distress secondary to pain. SKIN: No rashes. Warm and dry. HEENT: Atraumatic and normocephalic. Eyes, ears, nose, and throat examination normal. NECK: Supple. No JVD or nodes. CHEST: Bilaterally symmetrical. HEART: S1 and S2, regular. No gallops or murmurs. LUNGS: Clear to auscultation. No wheezes. ABDOMEN: Soft. Positive tenderness in the right upper quadrant. No rebound. No guarding. No masses. Positive bowel sounds. Full range of motion in all joints. EXTREMITIES: No cyanosis, clubbing or edema. NEUROLOGICAL: Awake, alert, and oriented x3 with no focal neurological deficits.
ADMITTING LABORATORY DATA: WBC count of 7200, H&H of 13.8 and 39.8, platelet count 212,000, MCV 84.8. Sodium 140, potassium 3.6, chloride 106, bicarbonate 24. BUN 16 and creatinine 1.6. Blood sugar 130, total protein 8, albumin 4.2, calcium 9, total bilirubin 1.0, alkaline phosphatase 68, AST 18, ALT 11, amylase 34, lipase 34. UA was negative and also a CT scan of the abdomen and pelvis was done, which was also negative.
IMPRESSION: Abdominal pain, possible cholecystitis.
HOSPITAL COURSE: The patient was admitted, and surgical consult was called. He was kept NPO, started on IV Maxipime, and HIDA scan was ordered and was given morphine sulfate p.r.n. for pain. During the course of the hospital stay, the patient had a HIDA scan done, which came back negative for acute cholecystitis. However, he developed acute gouty arthritis of his right ankle, for which he was seen in consultation by Rheumatology, and his right ankle was aspirated and then intraarticular steroid was injected. Today, he is feeling much better, and he was able to tolerate regular food, and he had no complaints of abdominal pain or nausea, so he is being discharged today in stable condition.
DISCHARGE INSTRUCTIONS: Diet: Two gram sodium, low cholesterol. Activity: As tolerated.
MEDICATIONS: Vasotec 20 mg b.i.d., Coreg 6.25 mg b.i.d., Lasix 40 mg b.i.d., K-Dur 20 mEq daily, Plavix 75 mg once daily, Zocor 20 mg once daily, and colchicine 0.6 mg once daily. He is to follow up with us in two weeks.
