DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Acute cholecystitis, status post cholecystectomy.
2. Subacute small bowel obstruction.
3. Atrial fibrillation.
4. Hypertension.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old with significant past medical history of hypertension, mitral valve prolapse, atrial fibrillation, pancreatic cyst, mini CVA, ventral hernia, and prostate cancer, status post radiation therapy, who comes to the ER with abdominal pain, nausea, and vomiting for the past two days. Nausea and vomiting was five to six times a day, and most of the time, it contains food and denies any blood in the vomiting, and abdominal pain is in the right upper quadrant. Constant pain, no radiation.
The patient denies any fever or chills. The patient denies chest pain, palpitations, sweating, shoulder pain, dysuria, and diarrhea for the past one day, soft, non-watery, four bowel movements yesterday. The patient denies any travel history, eating outside or black stools. The patient has a history of colonoscopy. As per the patient, basically this was normal.
PAST MEDICAL HISTORY: No diabetes mellitus. Positive for hypertension, positive for mitral valve prolapse, positive for atrial fibrillation, positive for the pancreatic cyst, status post removal, mini CVA with no residual effects, and positive ventral hernia, positive for prostate cancer six years ago status post radiation therapy.
ALLERGIES: ASPIRIN AND PENICILLIN.
MEDICATIONS: At the time of admission, Altace 5 mg p.o. daily and digoxin 250 mcg p.o. daily.
SOCIAL HISTORY: The patient was a smoker for the past 18 years but quit smoking 13 years ago.
PHYSICAL EXAMINATION: VITAL SIGNS: At the time of admission, temperature 98.8, pulse 76, respirations 22, blood pressure 146/82, and O2 saturation 96% on room air. GENERAL: The patient is alert, awake, and appears comfortable. ABDOMEN: Positive right upper quadrant tenderness and Murphy sign is positive and large ventral hernia felt in the epigastric region, which is reducible. Appendectomy scar is present. Bowel sounds are present.
LABORATORY AND DIAGNOSTIC DATA: At the time of admission, WBC 14,200, hemoglobin 15, BUN and creatinine 28 and 1.1, albumin 4.1, SGOT and SGPT 34 and 18, alkaline phosphatase 72, total bilirubin 1.9, digoxin 1.2, PT, PTT, and INR is 31.6, 15.4, and 1.2, lipase 34, and amylase 64.
EKG showed atrial fibrillation with 64 beats per minute and LVH. Obstructive series was done, which showed nonspecific bowel gas pattern, and CT of the abdomen showed thickened gallbladder wall. Chest x-ray, cardiomegaly is present, no infiltrates, no pulmonary vascular congestion.
HOSPITAL COURSE: The patient was admitted to the general medical floor. The patient was kept NPO and cholecystectomy was done. The patient recovered well from the cholecystectomy, and the patient developed small bowel obstruction, and the patient was kept NPO and on nasogastric suction. The patient responded well, and the patient’s small bowel obstruction resolved without any surgical intervention.
When the patient was in the hospital, the patient developed a fever and rise in the WBC count. Chest x-ray was performed, which showed hypoinflated lungs with bibasilar pleural parenchymal densities and congestive changes. Thinking that the patient developed aspiration pneumonia, the patient was treated with clindamycin and cefepime, and swallow evaluations were performed, and as per their suggestion, the patient was kept on mechanically soft diet with nectar thick liquids.
The patient’s pneumonia responded well. The patient’s fever decreased and WBC count improved, and as the patient felt better, we discharged the patient to the rehab center.
