Author Pei ChungAnderson HealthcareMay 8th, 2024 12:20pm

Note Date/Time May 8th, 2024 12:16pm

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 History & Physical Report SignedPatient: Towell,Alexander R MR#: M000499848 DOB: 08/04/1975 Acct:V00003663948Age: 48 ADM Date: 05/08/24 Loc: ANH3MEDSUR 327-01 Attending Dr: Pei Chang Chung M.D.cc: Chung, Pei Chang MD; Gaudreault, Rachel N. PA-C; Suthan***, Nanthini MD~H&P: HPIHistory of Present IllnessDate/Time: 05/08/24 12:12Chief Complaint: abdominal pain

Narrative: The patient is a 48-year-old male well known to my service from previous sigmoidcolectomy secondary to metastatic sigmoid colon cancer. The patient presents complaining of crampy abdominal pain, nausea, constipation over the last month. The patient reports the symptoms have been progressively worsening. Workup, including imaging, is significant for small bowel obstruction. The patient has been admitted to my service and made NPO, NG tube decompression has been initiated. The patient reports he did have some diarrhea yesterday after takingsome laxatives.Review of SystemsReview of Systems: All systems reviewed & are unremarkable except as noted in HPI and below PMFSHPast Medical HistoryMedical History (Reviewed 05/08/24 @ 12:14 by Pei Chang Chung, MD)Colon cancerIron deficiency anemia (Unknown)Mass of colon (~12/2021)ObesitySurgical HistorySurgical History (Reviewed 05/08/24 @ 12:14 by Pei Chang Chung, MD)History of colon resection 12/29/2021 - hand assisted laparoscopic sigmoid colectomy with mobilization of the splenic flexureHistory of partial thyroidectomyFamily HistoryFamily History (Reviewed 05/08/24 @ 12:14 by Pei Chang Chung, MD)Father Hypertension Malignant neoplasm of prostateMother Deceased COPD (chronic obstructive pulmonary disease)Social HistorySocial History (Reviewed 05/08/24 @ 12:14 by Pei Chang Chung, MD)Smoking status: Never smoker Second hand tobacco smoke exposure: No Alcohol intake: never Drinks per week: 1 Alcohol use details: LAST DRINK 2015 Substance use: never Substance use type: does not use Do You Feel Safe in your Home?: Yes Lack of Transportation: No Lack of Food: Never True Current Housing: I Have Housing Concerned About Future Housing: No Difficulty Paying Gas/Electric Bills: No Difficulty Paying for Meds: No Currently Unemployed: No Education: Master’s Degree or Higher Difficulty w/ Childcare or Family Care: No Living arrangements: with family Additional living arrangements comments: LIVES WITH SIGNIFICANT OTHER Spiritual care concerns: No MedsHome Medications and Allergies Home Medications Medication Instructions Recorded Confirmed Typecholecalciferol (vitamin D3) 25 25 mcg PO DAILY 01/12/24 05/08/24 Historymcg (1,000 unit) tablet (Vitamin D3) levothyroxine 100 mcg tablet 100 mcg PO DAILY 01/12/24 05/08/24 Historymultivitamin with minerals-folic 1 tablet PO DAILY 01/12/24 05/08/24 Historyacid 200 mcg chewable tablet (Adult Multivitamin Gummies) AllergiesAllergy/AdvReac Type Severity Reaction Status Date / TimeNo Known Allergies Allergy Verified 05/08/24 02:36Vital Signs Vital Signs - 24 hr 05/07/2420:12 05/07/2420:12 05/07/2422:58Temperature 37.1 C 37.1 C Pulse Rate 72 76 61Respiratory Rate 17 19 18Blood Pressure 143/76 H 143/76 H 123/68Pulse Oximetry 100 100 98Oxygen Delivery Room Air 05/08/2401:00 05/08/2402:26 05/08/2406:00Temperature 36.4 C 36.4 CPulse Rate 66 62 70Respiratory Rate 18 16 16Blood Pressure 137/76 149/80 H 132/72Pulse Oximetry 100 98 100Oxygen Delivery 05/08/2408:25Temperature Pulse Rate Respiratory Rate Blood Pressure Pulse Oximetry Oxygen Delivery Room AirExamConst: General: cooperative, comfortable and no acute distress HENMT: Head: normal to inspection, normocephalic and atraumatic Eyes: General: appearance normal, both eyes and all related structures Neck: Neck: normal visual inspection, full ROM and no lymphadenopathy Resp: Auscultation: clear to auscultation bilaterally Cardio: Rate: regular rate Rhythm: regular rhythm GI: Inspection: normal to inspection, distended and incision GI Palp: No abdominal tenderness, Yes Soft to palpation, No Tenderness to palpation present (GI), No Guarding due to palpation present (GI) and No Rigid due to palpation Skin: General skin exam: normal color and no rashes or lesions noted Neuro: General: patient oriented x3 and CN’s II-XI intact bilaterally Extrem: General: normal to inspection and full ROM Psych: Appearance: grossly normal H&P: ResultsLabsLabs: Short CBC 05/07/24 Range/Units 21:05 WBC 4.9 (4.5-10.0) K/mm3Hgb 11.5 L (14.0-18.0) g/dLHct 35.5 L (42.0-52.0) %Plt Count 240 (150-375) k/mm3 BMP 05/07/24 21:05Sodium 139Potassium 3.6Chloride 107Carbon Dioxide 20 LBUN 25 HCreatinine 1.30Glucose 93Calcium 9.2 Liver Function 05/07/24 Range/Units 21:05 Total Bilirubin 0.5 (0.2-1.3) mg/dLAST 24 (17-59) U/LALT 15 (6-50) U/LAlkaline Phosphatase 85 (38-126) U/LAlbumin 4.7 (3.5-5.1) g/dL Urine 05/07/24 Range/Units 21:05 Urine Color Yellow (Yellow) Urine Appearance Clear (Clear) Urine pH 5.0 (5.0-9.0) Ur Specific Gravity 1.092 H (1.001-1.035) Urine Protein Negative (Negative) mg/dLUrine Glucose (UA) Negative (Negative) mg/dLAssessment and PlanAssessment and plan(1) Small bowel obstruction: Code(s):K56.609 - Unspecified intestinal obstruction, unspecified as to partial versus complete obstruction Status: Acute Assessment and

Plan: exam benign, cont conservative mgmt c NPO, NG decompression, will get SBS for further evalThis report may have been done utilizing a voice recognition system. Attempts have been made to correct errors. However, there may be uncorrected grammatical,spelling, and recognition errors present.Report Initialized date/time: Chung, Pei Chang MD 05/08/24 / 1216Electronically signed by: Chung, Pei Chang MD 05/08/24 1220