DATE OF SERVICE: MM/DD/YYYY
SUBJECTIVE: The patient was seen and examined on rounds. At the time of evaluation, he denies any significant cough, sputum production, chest pain, palpitations, nausea or vomiting. The patient does feel dyspneic but no significant change in the last two to three days. He does feel like his abdominal pain has improved. Actually, he has an appetite.
OBJECTIVE:
VITAL SIGNS: T-current 96.6, pulse 88, oxygen saturation 96% on room air with respiratory rate of 20, and blood pressure 106/76.
GENERAL: The patient is alert and oriented x3.
HEART: Regular rate and rhythm.
LUNGS: Diminished at the bases bilaterally. No wheezes, rales or rhonchi.
ABDOMEN: Distended. Bowel sounds are present, some of which are high pitched. There is no significant tenderness to palpation. No rigidity. No peritoneal signs.
EXTREMITIES: No clubbing, cyanosis or edema.
LABORATORY DATA: Reviewed. ABG shows a pH of 7.46, pCO2 of 28, pO2 of 74, bicarbonate of 22, oxygen saturation 95% on room air. Electrolytes significant for phosphorus of 1.3, magnesium within normal limits at 2.2. BUN and creatinine stable. Sodium 139, potassium 3.2, chloride 104, bicarbonate 26, calcium 7.4, total bilirubin 12.8, alk phos of 344, AST of 322, ALT of 100, total protein of 5 and albumin of 2.0. CBC shows a white count of 12.2, hemoglobin of 9.8, hematocrit of 29.4, and a platelet count of 304. Differential shows 76% granulocytes, 2% bands. PT/INR 17.8 and 1.5 respectively.
ASSESSMENT AND PLAN:
1. Acute pancreatitis, likely due to alcohol ingestion. Symptoms are essentially resolved. The patient’s appetite has returned. He has had no significant nausea, vomiting, and abdominal pain has resolved; however, at this point in time, the patient is demonstrating abdominal distention. A KUB obtained today shows evidence of adynamic ileus.
2. Adynamic ileus, likely associated with acute pancreatitis. We will make the patient n.p.o. We will replace electrolytes and place an NG tube to low wall suction to help. We have asked nursing to ambulate the patient. We will limit narcotic pain medication to monitor response.
3. Acute hepatocellular injury superimposed on chronic hepatic dysfunction. Discriminant function remains less than 35, no indication for institution of corticosteroids, Trental. We will continue to monitor.
4. Alcohol abuse with history of delirium tremens, and it does appear that the patient underwent lorazepam detox in the unit. We will continue with ASE scores and p.r.n. Ativan.
5. Hyponatremia, essentially resolved.
6. Lactic acidosis, resolved.
7. Acute kidney injury, multifactorial in nature. Creatinine trended back towards baseline. We will avoid any nephrotoxic agents.
8. Hepatic encephalopathy, presently resolved. We will continue lactulose and Xifaxan.
9. Respiratory alkalosis, underlying etiology may be related to pain or abdominal discomfort and distention. We will investigate for the possibility of PE given the underlying hepatic function, acute pancreatitis, and hospitalization.
10. Code status: Full code.
