DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Rule out ileus.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female admitted for an elective L2 through L5 decompression secondary to spinal stenosis and neurogenic claudication. The patient is status post L2 to L5 decompression and fusion. The patient had episode of nausea and vomiting last night, of undigested food. No consequent emesis nor hematemesis. The patient was complaining of abdominal pain and distention. She states that her last bowel movement was yesterday, of formed moderate amount. She is denying any diarrhea. No melena or any hematochezia. No fevers, no colds or chills. No chest pain or shortness of breath.
PAST MEDICAL HISTORY: Significant for hypertension, hypothyroidism, hyperlipidemia, GERD, thyroid cancer, urinary incontinence, and spinal stenosis.
PAST SURGICAL HISTORY: Cholecystectomy, thyroid resection, hysterectomy, bladder surgery, back surgery, and tonsillectomy.
SOCIAL HISTORY: Negative tobacco and ETOH abuse.
FAMILY HISTORY: Noncontributory.
ALLERGIES: NKDA.
MEDICATIONS: Proventil, Norvasc, bisacodyl, calcitriol, Catapres, Zetia, hydrochlorothiazide, Synthroid, lidocaine, Cozaar, Reglan, morphine sulfate, Protonix, oxycodone, and potassium chloride.
REVIEW OF SYSTEMS: A 14-point review of systems was completed. Pertinent positives are in the history of present illness.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 97.8 degrees, heart rate 76, respirations 20, and blood pressure 146/52.
NEUROLOGICAL: Alert and oriented x3.
HEART: S1 and S2 heard.
LUNGS: Clear to auscultation.
ABDOMEN: Distended. Decreased bowel sounds. Tender to palpation in lower quadrants without any guarding or rigidity.
LABORATORY DATA: White blood cells 14.2, hemoglobin 12.6, hematocrit 36.8, MCV 83.6, and platelet count 394. Sodium 132, potassium 3.6, chloride 98, CO2 of 24, BUN 26, creatinine 1.4, and calcium 7.2. Total bilirubin 0.6, alkaline phosphatase 68, ALT 42, AST 36, and BNP 284.
IMPRESSION:
1. Nausea and vomiting.
2. Abdominal pain/distention, questionable related to ileus versus obstruction.
3. Leukocytosis.
4. Status post L2 through L5 decompression and fusion.
5. Hypertension.
6. History of hypothyroidism.
7. History of dyslipidemia.
8. History of thyroid cancer/thyroid resection.
PLAN:
1. We will keep the patient NPO.
2. We will do KUB stat to rule out ileus.
3. IV fluids.
4. Mobilize the patient.
5. Decrease pain medications.
6. Correct electrolytes.
7. Further plans will be made per Dr. Jane Doe.
