DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Pancreatitis.
HISTORY OF PRESENT ILLNESS: The patient complained of right shoulder pain after a fall approximately one week ago. He stayed home taking care of himself with Extra Strength Tylenol, approximately 2 tablets every 4 to 6 hours. He states his last dose was prior to the day of admission. The patient denies any dyspepsia, dysphagia or odynophagia. He drinks approximately three beers a day when he is working and approximately nine or plus on the weekends. He complains of a decrease in appetite during this week secondary to pain and occasionally noticed some nausea and some vomiting. He denies any abdominal pain. He states his stools had been brown. According to the significant other, she did not notice any change in the patient’s physical condition until the day of consultation, the patient is now jaundiced. CT of the brain was done secondary to the patient having decrease in level of consciousness and change in mental status with some confusion. Also, right shoulder x-ray was performed, which showed a fracture and a dislocation of his right shoulder with reduction being done showing normal alignment. The patient also underwent an ultrasound, which showed cholelithiasis with mural thickening of the gallbladder wall with the common bile duct measuring 4.5 mm.
PAST MEDICAL HISTORY: Right shoulder dislocation a week prior to admission but reduction upon admission, hypertension, and arthritis of both knees.
PAST SURGICAL HISTORY: Bilateral knee surgery.
SOCIAL HISTORY: The patient smokes approximately a pack a day. He states this is down for him. He has a history of heavy alcohol use.
FAMILY HISTORY: Father with a history of kidney problems and prostate problems. Mother has history of heart problems. Denies any colorectal problems in the family with cancer, lung or bleeding disorders.
ALLERGIES: None.
MEDICATIONS: Folic acid, Librax, thiamine, and Protonix.
PHYSICAL EXAMINATION: Blood pressure is 106/64, pulse 76, and respirations 18. The patient is afebrile at 98.2. The family is at bedside at this time. The patient is very slow to respond with a facial droop noted. According to the patient’s family, this is normal for him. Skin is warm and dry. Sclerae icteric. Skin is jaundiced. The patient has a right shoulder sling on. Large ecchymotic area noted around shoulder and biceps. Chest is essentially clear and bilaterally expanding. Respirations are even and unlabored. Heart: S1 and S2. No rubs, murmurs, or gallops. Abdomen is soft and nontender with bowel sounds throughout. Hepatomegaly noted. No masses palpated. The patient is moving all extremities, but right arm is very weak secondary to fracture and dislocation, presently in a sling.
LABORATORY DATA: Reviewed. White count 14.6, hemoglobin 8.6 and hematocrit 24.4, repeat values at 9.8 and 28.2 with white count coming down to 12.5. PT/INR 16.4 and 1.32. Hepatic enzymes: Total bilirubin noted to be 8.8 on admission with an alkaline phosphatase of 138 with an ALT of 798, AST of 218, amylase 128, and lipase of 144. On day of consultation, total bilirubin was down slightly at 8, alkaline phosphate 154 with ALT of 614, AST of 196, amylase 124, and lipase of 151.
IMPRESSION:
1. Elevated liver function tests secondary to questionable:
a. Alcohol abuse.
b. Tylenol overdose.
c. Hepatitis.
d. Biliary disease.
2. Anemia, normocytic normochromic at this time, questionably secondary to large bruising on the right shoulder. The patient is status post red blood cells given.
3. Pancreatitis, which is mild, likely due to alcohol abuse.
4. History of fracture of humerus with dislocation of the shoulder, status post reduction in the emergency department.
5. Leukocytosis.
6. Alcohol and tobacco abuse.
RECOMMENDATIONS:
1. At this time, STAT Tylenol level to rule out Tylenol overdose. Start Mucomyst at this time.
2. PPI therapy.
3. Ammonia level.
4. Monitor H and H at this time.
5. Further recommendations pending the patient’s progress.
