DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient was seen and examined at bedside. The patient’s son was in the room as well. The patient denies any nausea or vomiting at the current time. Continues on Neo-Synephrine, which is being weaned down. Blood pressure is stable.
OBJECTIVE:
VITAL SIGNS: Heart rate 106, blood pressure 96/56, and respiratory rate 20.
GENERAL: NAD, conversant.
HEENT: Anicteric sclerae. No lid lag or proptosis. PERRLA. Tonsils not visible.
NECK: Nontender. No masses.
HEART: PMI nondisplaced. S1 and S2 heard. No bipedal edema.
LUNGS: Clear to auscultation. Normal respiratory effort.
ABDOMEN: Soft, BS normal, no HSM.
NEUROLOGICAL: The patient is alert, awake, oriented to self, recognized the examiner and her son. The patient knows she is in the hospital.
LABORATORY DATA: Studies done included CBC with white blood cell count of 14.4, hemoglobin 12.4, hematocrit 36.8, and platelet count 276. BMP with blood glucose of 128, BUN 7, creatinine 0.78, sodium 140, potassium 3.2, calcium 8.2, CO2 of 25, and anion gap 14. Lactic acid done yesterday was elevated at 3.5. Abdominal x-ray is showing no evidence of bowel obstruction. Urine culture is showing no growth.
ASSESSMENT AND PLAN:
1. Right internal carotid artery stenosis: Status post internal carotid artery stent. On aspirin and Plavix.
2. Hypertension: The patient has been running low blood pressure since her stent placement. On IV fluids and Neo-Synephrine, also on midodrine. Neo-Synephrine is being weaned down.
3. Multivessel coronary artery disease: The patient will need outpatient evaluation for coronary artery bypass graft. She will need to be on aspirin and Plavix for now given her stent.
4. Nausea and vomiting: Improved. Exact etiology unclear. She does not seem to be in acute pain. Abdominal x-ray does not show any acute abnormality.
5. Metabolic acidosis: Likely related to her nausea and vomiting, noted yesterday on her BMP, resolved.
6. Elevated lactic acid level: Lactic acid level yesterday elevated. This is likely secondary to hypovolemia/hypoperfusion. We will recheck.
