Author Anthony ZychAnderson HealthcareMay 8th, 2024 7:04pm

Note Date/Time May 7th, 2024 9:04pm

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 Emergency Room Visit Note 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: Gaudreault, Rachel N. PA-C; Suthan***, Nanthini MD; Zych, Anthony H. MD~HPI - Abdominal PainGeneralChief Complaint: Abdominal PainStated Complaint: bowel obstruction; CT scan earlier todayTime Seen by Provider: 05/07/24 20:19Source: patient and old records reviewedMode of arrival: ambulatoryLimitations: no limitationsHistory of Present IllnessHPI narrative: Patient is a 48-year-old male who presents the ED with report of bowel obstruction. Patient has history of partial colectomy in 2019 for colon cancer,performed by Dr. Chung. He has since underwent chemotherapy under Dr. Arshad. He states a history of chronic constipation, but states over the last 1 month, he has had increased difficulty with constipation. He has required taking laxatives frequently to have a bowel movement. He does note his stools have been dark in color over the last few weeks. He had blood work done recently andwas noted to be newly anemic. Following with Dr. Arshad for this. He is not onany blood thinners. Denies BRBPR. Has been having intermittent abdominal pain,mostly throughout his upper abdomen over the last 1 week, with intermittent nausea and vomiting. He underwent outpatient CT scan today at Saint Anthony’s Hospital in Alton which showed a partial small-bowel obstruction. He was then sent to the ED for further evaluation. Patient denies fevers.Related Data Home Medications Medication Instructions Recorded Confirmedcholecalciferol (vitamin D3) 25 25 mcg PO DAILY 01/12/24 01/12/24mcg (1,000 unit) tablet (Vitamin D3) levothyroxine 100 mcg tablet 100 mcg PO DAILY 01/12/24 01/12/24multivitamin with minerals-folic 1 tablet PO DAILY 01/12/24 01/12/24acid 200 mcg chewable tablet (Adult Multivitamin Gummies) AllergiesAllergy/AdvReac Type Severity Reaction Status Date / TimeNo Known Allergies Allergy Verified 05/07/24 20:16Review of SystemsReview of Systems: CONSTITUTIONAL: Denies fever, chills, or sweats.GASTROINTESTINAL: See HPI.GENITOURINARY: Denies dysuria or hematuria.MUSCULOSKELETAL: Denies back pain, extremity pain, myalgia.NEUROLOGIC: Denies headache, dizziness, numbness, or weakness. All systems reviewed & are unremarkable except as noted in HPI and below PMFSHPast Medical HistoryMedical History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)Colon cancerIron deficiency anemia (Unknown)Mass of colon (~12/2021)ObesitySurgical HistorySurgical History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)History of colon resection 12/29/2021 - hand assisted laparoscopic sigmoid colectomy with mobilization of the splenic flexureHistory of partial thyroidectomyFamily HistoryFamily History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)Father Carcinoma of colon HypertensionMother Deceased COPD (chronic obstructive pulmonary disease)Social HistorySocial History (Reviewed 05/07/24 @ 21:08 by Rachel N. Gaudreault, PA-C)Smoking status: Never smoker Second hand tobacco smoke exposure: No Alcohol intake: former Drinks per week: 1 Alcohol use details: LAST DRINK 2015 Substance use: never Substance use type: does not use Living arrangements: with family Additional living arrangements comments: LIVES WITH SIGNIFICANT OTHER Spiritual care concerns: No Exam

Narrative: GENERAL: Well appearing, well-nourished, non-toxic, in no acute distress.HEAD: Normocephalic, atraumatic.RESPIRATORY: Airway patent, respirations nonlabored. Clear to auscultation bilaterally, no rales, rhonchi, wheezing.CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs, or gallops.ABDOMINAL: Soft, diffuse tenderness throughout upper abdomen, worst throughout epigastric region, nondistended. Normoactive BS. MUSCULOSKELETAL: Moves all extremities. No gross deformities.SKIN: Warm, dry, normal color.NEURO: A&O X3. Speech clear. Cranial nerves II-XII grossly intact. Steady gait. No ataxic movements. PSYCHIATRIC: Appropriate mood and affect. Normal interaction.CourseVital SignsVital signs: Vital SignsTemperature 98.7 F 05/07/24 20:12Pulse Rate 72 05/07/24 20:12Respiratory Rate 17 05/07/24 20:12Blood Pressure 143/76 H 05/07/24 20:12Pulse Oximetry 100 05/07/24 20:12Oxygen Delivery Room Air 05/07/24 20:12Temperature 98.7 F 05/07/24 20:12Pulse Rate 61 05/07/24 22:58Respiratory Rate 18 05/07/24 22:58Blood Pressure 123/68 05/07/24 22:58Pulse Oximetry 98 05/07/24 22:58Oxygen Delivery Room Air 05/07/24 20:12MDM - Abdominal PainMDM NarrativeMedical decision making narrative: Patient presented to ED with abnormal outpatient CT scan of his abdomen which showed SBO. History of colon cancer with partial resection. Has had issues with constipation, dark stools over the last few weeks. Vital signs are stable upon arrival. DRE performed in the ED with brown stool, guaiac negative. Cbc without leukocytosis. Hemoglobin 11.5, increasing from recent records. Normal platelets. CMP unremarkable. Lactic acid within normal limits at 0.7. Urinalysis with evidence of dehydration, no signs of infection. Fluids ongoing. CTreport was faxed from outside hospital, shows dilated loops of small bowel with transition zone in right lower abdomen, consistent with SBO. Discussed case with Dr. Chung, general surgery, agreed with plan for NG tube, will admit primarily. Patient has remained stable throughout ED stay. Denies current painor nausea. Keep NPO.Discussed case with Dr. Hopen, hospitalist, regarding comorbidity of hypothyroidism - on levothyroxine therapy. Patient does not have any other significant past medical history. She advised to given patient 1/2 his normal home dose of levothyroxine in the IV formulation while patient is NPO. She did not feel his workup otherwise warranted a medicine consult at this time. Will defer official consult for now. Will be happy to consult if other acute medicalissues developed during hospitalization.Medical RecordsAttestation: I reviewed the patient’s medical records.Lab DataAttestation: I reviewed the patient’s lab results. 05/07/24 21:05 05/07/24 21:05 Labs: Lab Results 05/07/24 Range/Units 21:05 WBC 4.9 (4.5-10.0) K/mm3RBC 4.38 L (4.6-6.20) M/mm3Hgb 11.5 L (14.0-18.0) g/dLHct 35.5 L (42.0-52.0) %MCV 81.1 (80-100) flMCH 26.3 (26-34) pgMCHC 32.4 (32-36) g/dlRDW 12.6 (11.5-14.5) %Plt Count 240 (150-375) k/mm3MPV 10.8 H (7.4-10.4) flImmature Gran % (Auto) 0.4 (0-0.5) %Neut % (Auto) 66.6 (45.5-73.1) %Lymph % (Auto) 22.0 (18.3-44.2) %Mono % (Auto) 8.4 (2.6-8.5) %Eos % (Auto) 2.2 (0-4.4) %Baso % (Auto) 0.4 (0.2-1.2) %Lymph # (Auto) 1.08 (0.9-3.2) K/mm3Mono # (Auto) 0.4 (0.1-0.6) K/mm3Eos # (Auto) 0.1 (0-0.3) K/mm3Baso # (Auto) 0.0 (0.0-0.1) K/mm3Abs Immat Gran (auto) 0.02 (0.00-0.031) K/mm3Absolute Neuts (auto) 3.3 (1.3-6.7) K/mm3Absolute Nucleated RBC 0.000 (0.0-0.012) K/mm3Nucleated RBC % 0.0 (0.0-0.2) %Sodium 139 (137-145) mmol/LPotassium 3.6 (3.4-5.0) mmol/LChloride 107 (98-107) mmol/LCarbon Dioxide 20 L (22-30) mmol/LAnion Gap 12 (4-12) mmol/LBUN 25 H (9-20) mg/dLCreatinine 1.30 (0.7-1.3) mg/dLEstim Creat Clear Calc 70 ml/minEstimated GFR 59 (59 - ) Glucose 93 (65-110) mg/dLLactic Acid 0.7 (0.7-2.0) mmol/LCalcium 9.2 (8.4-10.2) mg/dLTotal Bilirubin 0.5 (0.2-1.3) mg/dLAST 24 (17-59) U/LALT 15 (6-50) U/LAlkaline Phosphatase 85 (38-126) U/LTotal Protein 8.0 (6.3-8.2) g/dLAlbumin 4.7 (3.5-5.1) g/dLLipase 71 (23-300) U/LUrine 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/dLUrine Ketones 1+ H (Negative) mg/dLUr Blood (Man) Negative (Negative) Urine Nitrate Negative (Negative) Urine Bilirubin Negative (Negative) Urine Urobilinogen 0.2 (<2.0) mg/dLLeukocyte Esterase Rfl Negative (Negative) LEU/ULImaging DataAttestation: I personally reviewed and interpreted this imaging study as follows:Radiologist’s impression: CT ABD/pelvis: Impression: There are dilated loops of small bowel measuring upto 3.5 cm with fecalization of bowel contents and transition zone within the right lower abdomen where there is twirling of a short-segment loop of small bowel with abnormal wall thickening, and surrounding engorged vessels/fat stranding. Findings are suspicious for acute small bowel obstruction, possibly partial. Further evaluation with endoscopy to exclude underlying neoplasm due to prior history of colon cancer. Prominent enlarged abdominal lymph nodes. These may be reactive or neoplastic given history of prior malignancy. Comparison to prior studies and attention on follow-up. Sclerotic focus in the left iliac bone, nonspecific given history of malignancy. Comparison with priorstudies were stability or evaluation with MRI or bone scan if clinically indicated. Status post colonic resection and anastomosis without suspicious findings around the anastomosis. Small free fluid in the pelvis.Discharge PlanDischargeClinical Impression: Small bowel obstruction, History of colon cancer, Status post partial resectionof colon, AnemiaPatient Disposition: Still a PatientCondition: StablePrescriptions:No Action levothyroxine 100 mcg tablet 100 mcg PO DAILY Adult Multivitamin Gummies 200 mcg Tablet,Chewable 1 tablet PO DAILY cholecalciferol (vitamin D3) [Vitamin D3] 25 mcg (1,000 unit) Tablet 25 mcg PO DAILY tramadol 50 mg tablet 50 mg PO Q6H PRN (Reason: pain) Qty: 7 0RFFollow-up/Referrals:Suthan***,Nanthini, MD [Primary Care Provider] - This 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: Gaudreault, Rachel N. PA-C 05/07/24 / 2104Electronically signed by: Gaudreault, Rachel N. PA-C 05/08/24 0041 Zych, Anthony H. MD 05/08/24 1904