Author Pei ChungAnderson HealthcareMay 9th, 2024 9:58am

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

Anderson Hospital 6800 State Route 162 Maryville, IL 62062 General Surgery Consult 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: Chung, Pei Chang MD; Gaudreault, Rachel N. PA-C; Suthan***, Nanthini MD~this was entered in error, as I already completed a history and physicalHistory of Present IllnessConsult detailsConsult date: 05/08/24Reason for consult: abdominal painPMFSHPast 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 (Updated 05/08/24 @ 02:31 by Abby E. Scanzoni, RN)Father Hypertension Malignant neoplasm of prostateMother 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: 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 AirResultsLabs 05/07/24 21:05 05/07/24 21:05 Labs: Abnormal lab results 05/07/24 Range/Units 21:05 RBC 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) %MPV 10.8 H (7.4-10.4) flCarbon Dioxide 20 L (22-30) mmol/LBUN 25 H (9-20) mg/dLUr Specific Gravity 1.092 H (1.001-1.035) Urine Ketones 1+ H (Negative) mg/dL Diabetes panel 05/07/24 Range/Units 21:05 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/LBUN 25 H (9-20) mg/dLCreatinine 1.30 (0.7-1.3) mg/dLGlucose 93 (65-110) mg/dLCalcium 9.2 (8.4-10.2) 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/dL Calcium panel 05/07/24 Range/Units 21:05 Calcium 9.2 (8.4-10.2) mg/dLAlbumin 4.7 (3.5-5.1) g/dL Pituitary panel 05/07/24 Range/Units 21:05 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/LBUN 25 H (9-20) mg/dLCreatinine 1.30 (0.7-1.3) mg/dLGlucose 93 (65-110) mg/dLCalcium 9.2 (8.4-10.2) mg/dL Adrenal panel 05/07/24 Range/Units 21:05 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/LBUN 25 H (9-20) mg/dLCreatinine 1.30 (0.7-1.3) mg/dLGlucose 93 (65-110) mg/dLCalcium 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/dLAll other labs normal.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: Chung, Pei Chang MD 05/08/24 / 1212Electronically signed by: Chung, Pei Chang MD 05/09/24 0958