Medical Case Studies New

HISTORY

The patient is a 71-year-old female who states Sunday evening when a storm hit, she started having nausea and vomiting.  Shortly thereafter she started having diarrhea.  She had a lot of company in for Thanksgiving but no one was really sick, including her husband and daughter and son-in-law who spent the weekend with them.  She said the diarrhea kind of stopped on Tuesday, but she has had persistent vomiting, abdominal pain and a lot of stomach bloating.  She called the office and got some Donnatal called in on Tuesday, but said it just persisted, so she came to the emergency room Wednesday.  She thought I was out of town, so she did not call the office for an appointment.  Nurses on the floor said she started having some fecal smelling material, so a G-tube was placed.  She has had 300 mL back immediately of brown colored material, and she said her stomach is feeling better, but she does not know if it is that or the pain medicine.  

PAST MEDICAL HISTORY

She has a long history of abdominal discomfort.  She had a history of pancreatitis, peptic ulcer disease and GERD.  She has had multiple dilatations by Dr. Kirby.  She has had 2 Nissen fundoplications by Dr. Weinstein.  She had a Racine procedure done in 1986 for slow liver and gallbladder dysfunction.  She has also had a lobectomy for a black spot on her lungs and a hysterectomy.  She has also had her gallbladder out.   

ALLERGIES

She is allergic to PENICILLIN, VERSED and CLEOCIN.  

CURRENT MEDICATIONS

1.            Nexium 40 milligrams a day.

2.            Lexapro 10 milligrams a day.

3.            Restoril 30 milligrams at night.

4.            Tranxene on a p.r.n. basis.

FAMILY HISTORY

Noncontributory. 

SOCIAL HISTORY

She is married with 1 child.  She has a husband of almost 50 years.  She has a 20-pack-year history of smoking but none in the last 20 years.  She does not drink alcohol at all.

OBJECTIVE

GENERAL:  When I see Ms. Jacob, she is in the bed with an NG tube in and saying her stomach is feeling better, but she says it could be the pain medicine.

HEENT:  Her oropharynx is dry, but she has had some ice chips just to keep it moist.  Her pupils are equal, round and reactive to light. 

NECK:  There are no carotid bruits. 

CHEST:  She has bilateral breath sounds distant in the bases, but she states to take deep breaths, it hurts her stomach. 

ABDOMEN:  She has positive bowel sounds but very hypoactive. 

CARDIAC:  Regular rate and rhythm with a 1/6 systolic murmur at the left sternal border. 

EXTREMITIES:  No edema.  She has multiple surgical scars on her abdomen.  

LABORATORY DATA

Includes a potassium of 3.2, glucose 133.  Her albumin is 4.0.  Calcium 9.7.  Amylase was normal at 78.  Lipase was 25.  Her white count was 11.2 with a left shift.  H and H 13.7 and 40.2.   

X-RAYS

X-ray report per Dr. Hermecz shows some air fluid levels and 1 larger air bubble of small bowel.  The ER doctor calls this partial small bowel versus ileus.  This film will be reviewed with radiology.  

ADMISSION DIAGNOSES

1.            Gastroenteritis versus ileus versus partial small bowel obstruction.  Nasogastric tube has helped. 

2.            Gastroesophageal reflux disease.

3.            Leukocytosis.

4.            Hypokalemia.

PLAN

Going to place in the hospital.  NG tube.  IV fluids.  Replace potassium.  IV Protonix.  Complete bowel rest except for ice chips.  Will repeat electrolytes, CBC and amylase in the morning along with magnesium.  She has been admitted to this hospital 2 or 3 times for the this in the past and it usually takes a couple days to resolve.  If it gets worse, will get surgical consult.