H&P #1

Identifying data:

  • Date & Time: 3/20/23
  • Full name: ———-
  • Address: ——-
  • Date of birth: –/–/–
  • Location: Flushing, NY
  • Source of information: Self via translator
  • Reliability: Reliable
  • Source of referral: Self

 

Chief Complaint: Nausea and vomiting x 3 days

History of Present Illness:

73 y/o M with PMHx CAD, HTN, HLD, DM2, hypothyroidism, hx H pylori, hx LT vocal cord carcinoma in situ c/o nausea, vomiting and bloating x 3 days. Reports multiple episodes of vomiting and symptoms are typically postprandial. Patient reports seeing chunks of food in emesis. Patient’s daughter admits patient has had 8lbs of unintentional weight loss over the past 1-2 months. Reports intermittent mild abdominal pain over past 1-2 months, 3/10 in severity, pain does not radiate. Admits to decreased appetite, constipation and decreased flatulence. Last BM 3 days ago. Patient states he has never had an endoscopy or colonoscopy. Denies fever, chills, hematochezia, melena, hematemesis, heart burn.

 

Past Medical History:

  • Coronary artery disease
  • Diabetes mellitus 2
  • Hypothyroidism
  • Hyperlipidemia
  • Hypertension
  • Left vocal cord carcinoma in situ s/p resection in 2021

Past Surgical History:

  • Left vocal cord resection/biopsy in 2021; due to carcinoma in situ; unknown surgeon; no complications
  • Carotid stent x 2 June 2022; NYPQ – unknown surgeon; no complications
  • Coronary stent placement June 2022; NYPQ – unknown surgeon; no complications

Medications:

  • Amlodipine 5 mg, 1.5 tablets oral daily
  • Aspirin 81 mg oral daily
  • Atorvastatin 40 mg tablet oral daily
  • Benazepril HCL 40 mg tablet oral daily
  • Clopidogrel (Plavix) 75mg oral, daily
  • Empagliflozin 10mg oral daily
  • Levothyroxine 125 mcg tablet oral daily
  • Linagliptin-metformin HCL 2.5-1000 mg tablet oral daily

Allergies:

  • No known drug allergies
  • No known food allergies
  • No known environmental allergies

Family History:

  • No known significant family history

Social History:

  • Smoking: ex-smoker, 20 pack years
  • Substance use: Denies alcohol use. Denies drug use.
  • Home situation: lives at home with daughter; independent in ADLs

 

Review of Systems:

  • General: Admits to weight loss and decreased appetite. Denies generalized weakness/fatigue, fever, chills, night sweats.
  • Skin, hair, nails: Denies discolorations, pigmentations, moles/rashes, changes in hair distribution or texture, pruritus.
  • Head: Denies head trauma, vertigo.
  • Eyes: Denies visual disturbances, eyelid swelling, pruritus, photophobia, lacrimation.
  • Ears: Denies ear pain, deafness, discharge, tinnitus.
  • Nose: Denies epistaxis, discharge, congestion
  • Mouth/throat: Denies sore throat, voice changes, bleeding gums.
  • Neck: Denies localized swelling/lumps, stiffness/decreased ROM
  • Breast: Denies lumps, nipple discharge, pain.
  • Pulmonary: Denies cough, dyspnea, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, wheezing, cyanosis, hemoptysis.
  • Cardiovascular: Admits to history of HTN. Denies chest pain, edema/swelling of ankles or feet, palpitations, irregular heartbeat, syncope, known heart murmur.
  • Gastrointestinal: Admits to nausea, vomiting, constipation, abdominal pain, decreased flatulence. Denies intolerance to specific foods, dysphagia, pyrosis, diarrhea, jaundice, hemorrhoids, rectal bleeding, hematochezia, melena, hematemesis.
  • Genitourinary: Denies urinary frequency, urinary urgency, nocturia, oliguria, polyuria, dysuria, incontinence, flank pain, hematuria, history of hernias.
  • Sexual History: Not currently sexually active. Denies history of STIs.
  • Musculoskeletal: Denies arthritis, muscle pain, deformity or swelling, redness.
  • Nervous system: Denies seizures, headache, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition/mental status/memory.
  • Peripheral vascular: Denies intermittent claudication, varicose veins, coldness or trophic changes, color changes, peripheral edema.
  • Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, history of DVT/PE.
  • Endocrine: Denies polydipsia, polyphagia, heat or cold intolerance, excessive sweating, goiter, hirsutism.
  • Psychiatric: Denies depression/sadness, anxiety, OCD.

 

Physical Exam:

Vitals:

  • BP: 121/64 (seated)
  • HR: 62 (regular)
  • RR: 18 (unlabored)
  • T: 98.1 F (oral)
  • O2: 96% (room air)
  • Height: 157cm    Weight: 63.7 kg    BMI: 25.84

General: AAO x 3, appears in no acute distress, well groomed, appears stated age

Skin: Warm & moist; non-icteric; no rashes or lesions noted

Head: Normocephalic, atraumatic, non-tender to palpation throughout

Eyes: Sclera white, cornea clear, conjunctiva pink. PERRLA. Visual fields full OU. EOM intact, no nystagmus.

Ears: No lesions, trauma, discharge noted to external ear.

Nose: Symmetrical. Nares patent bilaterally, nasal mucosa pink.

Sinus: Non-tender to palpation.

Mouth/pharynx: Mucosa pink and well hydrated. Pharynx non-erythematous. No exudates or lesions visualized. Uvula midline.

Neck: Trachea midline. Supple and non-tender to palpation. No cervical lymphadenopathy noted.

Cardiac: Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur.

Chest: Symmetrical, no deformities. Respirations unlabored, no accessory muscle use.

Lungs: Clear to auscultation bilaterally.

Abdomen: Abdomen is distended and soft. Bowel sounds normoactive in all four quadrants. Nontender, no guarding or rebound noted. No palpable masses.

Peripheral vascular: Pulses 2+ bilaterally in upper and lower extremities. No clubbing, cyanosis or edema noted.

Musculoskeletal: FROM (full range of motion) of all upper and lower extremities bilaterally. Non tender to palpation.

Male GU exam: exam not performed.

Rectal: exam not performed.

 

Differential Diagnosis:

  • Gastric carcinoma
  • Gastric outlet obstruction
  • Small/large bowel obstruction
  • Gastroparesis
  • Peptic ulcer disease
  • Gastritis
  • Irritable bowel syndrome

 

Workup:

  1. Labs
CBC w/ diff
RBC 4.23 *
HGB 12.3 *
CRIT 37.7 *
MCV 89.1
MCH 29.1
MCHC 32.6
RDW 14.6 *
PLT 352
MPV 8.3
NEUTP 68.4
LYMPHP 21.60
MONOP 7.6
EOSP 0.70
BASOP 0.60
NEUT 5.87
LYMPH 1.85
MONO 0.65
EOS 0.06
BASO 0.05

 

BMP
NA 126 *
K 5.7 *
CL 94 *
CO2 13 *
BUN 10.5
CREATININE 0.75
GLU 83
ANION GAP 19 *
CA 8.3 *

 

Coags
PT 11.3
APTT 30.6
INR 0.97

 

LFTs
TP 5.9 *
ALB 3.3 *
GLOB 2.6
TBILI 0.2
DBILI <0.1
IBILI Unable to calc
SGOT 25
AGPT 9
ALK 64

 

Pro-BNP 49

 

  1. Imaging
    1. CT abdomen/pelvis with IV contrast
      1. Impression: large partially obstructing mass arising from the gastric antrum as described with upstream dilation of the gastric body and fundus

 

Diagnosis: Gastric outlet obstruction secondary to large antral mass

 

Assessment:

73 y/o M c/o nausea, vomiting, bloating, loss of appetite, decreased flatulence and constipation x 3 days. Patient has had 8 lbs of unintentional weight loss over past months. Admits to intermittent abdominal pain x 1 month. Patient is afebrile and hemodynamically stable. On exam, abdomen is distended and nontender to palpation, bowel sounds normoactive in all 4 quadrants. Labs are significant for hyponatremia to 124, hyperkalemia to 5.7, hemoglobin/hematocrit 12.3/37.7. CT abdomen/pelvis reveals gastric outlet obstruction secondary to a large gastric antral mass.

 

Plan:

  1. NPO
    1. NGT with decompression
    2. Nutrition – TPN
  2. Monitor strict I/Os
    1. NGT; urine
  3. Trend labs
    1. CBC, BMP, LFTs
    2. Hyponatremia
      1. Sodium correction with hypertonic saline infusion 1-2mEq/L/hr; do not exceed 8 mEq/L/day
      2. Monitor basic metabolic panel for electrolyte correction
  4. DVT prophylaxis
      1. Enoxaparin 40 mg subq
  5. GI consult
    1. EGD with biopsy and staging
  6. Cardiology consult –> for surgical clearance
    1. Echo; troponin; ekg
  7. Surgery consult
    1. Robotic assisted partial gastrectomy scheduled 3/21
  8. Oncology consult
    1. Metastatic workup – CEA, CA19-9, CT chest
  9.  Other:
    1. Code – full
    2. Disposition – admit to surgical floor
    3. Medications –> switch to IV/IM if possible
      1. Labetalol IV 10mg
      2. Levothyroxine sodium IV 75 mcg
      3. Insulin glargine subq 13 units
      4. Insulin lispro subq 1-5 units
      5. Continue aspirin 81mg via NG tube