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ER SOAP Patient’s Name: Mr. M. Location: DRMC ED Date & Time: 6/7/12, 14:17 Subjective: Chief Complaint: 76 y/o male presents to Dubois Regional Medical Center ED stating, “For the past three days I have been having a lot of upper abdominal pain and a lot of "rifting". History of Present Illness: The presenting abdominal pain symptoms radiate in the epigastric area, right and left hypochondriac regions, and to the left shoulder. Pertinent positives: nausea, vomiting, alternating chills and diaphoresis, chest pains, eructation, and swollen, painful abdomen. The quality is described as constant, achy, sharp, shooting, and stabbing. Modifying factors: The symptoms are alleviated by nothing, the symptoms are aggravated by food, touching the area, and lying flat on back. Severity of pain: At its worst the pain was severe in the emergency department, 8/10, the pain is unchanged since onset three days ago. The patient has been recently seen by a physician, the patient's primary care provider, two days ago with similar presenting complaints. Patient's symptoms have worsened and persisted after given Prilosec without relief. Arrived with spouse. Care prior to arrival: none. Activity prior to arrival: none. Patient denies any recent travel, changes in diet or exercise habits, starting any other medications besides Prilosec, or exposure to anyone with a current illness. Myocardial infarction appeared negative at triage by lack of EKG abnormalities; cardiac enzymes pending at this time. Patient has HTN, hypercholesterolemia, and diabetes. Patient denies syncope or LOC, paroxysmal nocturnal dyspnea, edema, diarrhea, colicky pain, hematuria, hematemesis, flank pain, RLQ pain, or irritable bowel disease. History is negative for diverticulitis, esophageal strictures, heartburn, ulcers, gastritis, gastroenteritis, or ascites. Past Medical History: Allergies: Penicillin & Keflex – developed rash, Claritin – developed upset stomach. Comorbidities: Diabetes – NIDDM for 20 years; Hypertension for 15 years; Hypercholesterolemia for 15 years. Immunizations: Flu vaccine August 2011, Zostavax 2008, Pneumovax 2001, Tetanus 2001. Hospitalizations, Injuries, Surgeries: Skin Graft and Hand Surgery 2001; Hernia repair 2005. Trauma: Broken hand 2001. Oral Medications: 1. Simvastatin Oral 40 mg q.d. 2. Glyburide Oral 2.5 mg b.i.d. 3. Lisinopril Oral 10 mg q.d. 4. Omeprazole Oral 40 mg q.d. 5. 600 mg Ibuprofen q.d. as needed 6. No OTC supplements or other medications taken Reproductive History: One daughter who is 45 y/o. No sexual dysfunction stated. Youth Illnesses: None No history of renal disease, pulmonary disease, clotting disorders, or cancer. Patient denies any recent infection within last six months. No previous abdominal complaints or similar pain. Social History: Family: The patient lives with wife, one grown daughter lives in area, no siblings, parents and grandparents are deceased. Lifestyle: Active around the house. Does not exercise or follow any special diet. No recent travel in last six months. Patient hobbies include photography and horseback riding. Abuses: Denies smoking, drinking, or drug use. Marital status: Married 47 years, has monogamous relationship, still sexually active. Employment: Retired from post office. Financially stable, middle socioeconomic class. Support System: Wife, daughter and son-in-law live in the area. Wife and daughter present in ED with patient. Family History: There is no family history of renal disease, clotting disorders, appendicitis, cholecystitis, hepatitis, pancreatitis, diverticulitis, gastritis, irritable bowel disease, or GERD. Daughter has no known history of severe illness or disease. Family history shows genetic predisposition for diabetes, cardiovascular disease, hypertension, pulmonary disease, and cancer in both maternal and paternal parents and grandparents. Father died from lymphoma at 69 y/o. Mother had diabetes, HTN, and died from AMI at 80 y/o. Paternal grandfather died from lung cancer at 79 y/o. Paternal grandmother died from cerebral hemorrhage at 78 y/o. Maternal grandfather died from AMI at 85 y/o. Maternal grandmother died from metastasized breast cancer at 75 y/o. Review of Systems: General: Low energy level, fatigued, uncomfortable and in pain for past three days. Patient recognizes alternating chills and diaphoresis since pain onset. Denies history of depression or anxiety. HEENT: Head: Patient denies any swelling, redness, rashes, recent headaches, lymphadenopathy or current diaphoresis. Eyes: No change in vision, diplopia or eye pain. Ears: No noted hearing loss, no tinnitus. Nose: No epistaxis or nasal drainage. Throat: Consistent eructation and difficulty swallowing for past three days. Neck: Patient denies any masses, rash, erythema, or lymphadenopathy. Pulmonary: Patient denies any cough, wheezing, hemoptysis, tachypnea, or SOB. No history of pneumonia or TB exposure, asthma, or COPD. Chest/CV: Patient denies any palpitations. Patient has HTN for past 15 years, controlled with medication. Left sided chest pain radiating from epigastric and left hypochondriac regions; pain worse when lying flat on back. Vascular/Heme: No history of gangrene, DVT, aneurysm, blood or clotting disorders, or anemia. Denies increased bleeding, bruising, or lymphadenopathy. G.I.: Decreased appetite that started three days ago. Patient complains of abdominal pain and distention, nausea, vomiting; worse after eating. Patient denies any diarrhea. Patient has hypercholesterolemia for past 15 years, controlled with medication. Prior GI history unremarkable without any history of appendicitis, diverticulitis, IBD, gastritis, or cholecystitis. G.U.: Afebrile, no hematuria. No dysuria, incontinence, or nocturia. GYN: No history of sexually transmitted disease. Patient denies any penile discharge, pain, discomfort, rashes, or lesions. MS/Extremities: Patient denies any edema, cyanosis, muscle aches, pain or swollen joints. No deformities or current joint or back pain. Rheumatic: No history of gout, rheumatic arthritis, or lupus. Endocrine: Has diabetes mellitus type II for past 20 years, on medication for but still uncontrolled. No history of thyroid disease. Denies tremors, polyuria, polyphagia, or polydipsia. Patient complains of heat and cold fluctuations. Skin/Dermatological: No new rashes, pruritus, or ecchymosis. Denies any irregular moles or changes in hair distribution. Patient denies having been bitten by or removal of any ticks. Neurological: There is no history of seizures, stroke, syncope, or memory changes. Objective: 14:25 B/P: 138/84, Pulse: 80, RR 20, T 98.7, Pulse Ox 98% RA, Pain 8/10, Wt. 192, Ht. 5’10” General: Alert and oriented X3, in obvious pain, uncomfortable. Well developed, laying down in bed. Well groomed and acting appropriately for age. BMI 27.5 - patient is overweight. Head: No apparent masses, scars, or lacerations. Normocephalic, atraumatic. No tenderness upon palpation. Eyes: Lids and lashes normal. Conjunctiva and sclera are non-icteric and not injected. Cornea within normal limits. Periorbital areas without swelling, redness, or edema. Pupils equal, round and reactive to light, EOM intact, visual fields respond to confrontation. No nystagmus or ptosis. Ears: Tympanic membranes are normal and external auditory canals are clear. No tenderness on palpation. Hearing equal responses bilaterally with scratch test. Nose: Septum not deviated. No nasal discharge, obstruction, or polyps. Nares patent. No tenderness on palpation. Throat: Oropharynx without redness, swelling, masses, exudates, or evidence of obstruction. Uvula midline. Normal gag reflex. Moist mucous membranes. Neck: Supple, trachea midline. No JVD, thyroidmegaly, masses, or lymphadenopathy appreciated. Full ROM without vertebral tenderness, no meningismus. Carotids without bruits. Pulmonary: No increased work of breathing, no retractions or nasal flaring. No rashes, lesions, or scars. Tenderness over left and right hypochondriac region upon palpation. No consolidation appreciated. Normal tactile fremitus and diaphragmatic excursion at 5 cm. Lungs have equal breath sounds bilaterally, clear to auscultation and percussion. No rales, rhonchi or wheezes appreciated. Chest/CV: Normal chest wall appearance and motion. PMI not visible at left 5th ICS/MCL. No lifts, heaves, rashes, scars, thrills or edema appreciated. Tenderness over left hypochondriac region upon palpation. Regular rate and rhythm on EKG, actual rate is 80 bpm, normal S1 and S2, no S3 or S4, no murmur, no gallops, no JVD. No pulse deficits. Vascular/Heme: Brisk capillary refill < 3 seconds. No active bleeding, bruises, lymphadenopathy, peripheral edema or cyanosis appreciated. Pulses equally bilaterally. Pulses Carotid Brachial Radial Dorsalis P Post Tibial R 2+ 2+ 2+ 2+ 2+ L 2+ 2+ 2+ 2+ 2+ GI: No deformities, striae, rashes, scars, or abnormal masses appreciated. Abdominal distention present. Bowel sounds: normal, in all quadrants, no bruits. Liver span 7cm by percussion. Spleen, bladder, and kidney margins normal without enlargement. McBurney’s point is nontender. Severe abdominal tenderness, in the right and left hypochondriac and epigastric regions. Predominant guarding with radiating pains to left shoulder. G.U. No dysuria or oliguria. Normal UA color and clarity. GYN: No penile discharge, lesions, rashes, or pain. FOBT negative, no hemorrhoid(s) or masses appreciated. MS/Extremity: Skin cool and dry. No clubbing, cyanosis, scoliosis, kyphosis, or lordosis appreciated. No CVA tenderness on palpation. No spinal deformities or pain upon palpation. Full active and passive range of motion. Motor strength 5/5 in all extremities. Rheumatic: No arthritis, Heberden or Bouchard nodes appreciated. No tenderness to palpation over joints or with AROM. Endocrine: No goiter or exophthalmos appreciated. Thyroid normal upon palpation. Skin: Skin warm and dry, normal color without rashes, lesions, or ecchymosis. Good capillary refill and skin turgor. No tenderness upon palpation of extremities. Neuro: Awake and alert, oriented to person, place, time, and situation. Cranial nerves I-XII grossly intact. Sensory grossly intact. Cerebellar exam normal. Normal gait. Normal DTR’s 2+, no Babinski. 14:31 Glasgow Coma Score: Total 15 Eye response: spontaneous 4, Verbal response: oriented 5, Motor response: obeys commands 6 Diagnostics: 14:20 ECG: Interpretation: Rate is 80 bpm. Rhythm is regular, Normal Sinus Rhythm with no ectopy. QRS Axis is Normal. PR interval is normal. QRS interval is normal. T waves are Normal. No ST changes noted. Clinical impression: No evidence of ischemia. 14:42 Fingerstick Blood Sugar: Interpretation: Abnormal: 216 14:42 CBC w/ Diff: Interpretation: WBC 13.48, Hgb 16.4; Hct 47.6; Plt Count 158, RBC 5.25, MCV 90.7, MCH 31.2, MCHC 34.5, MPV 11.3 14:42 CMP: Interpretation: BUN 12.7, Creatinine 0.95, Total protein: 8.0, Albumin 3.9, Globulin 4.1, Calcium 9.1, Bili Total 0.7, Na 135, Potassium 4.2, Chloride 100, CO2 25.6, AlkPhos 63, AST 9, ALT 20 14:42 Troponin-I: Interpretation: Normal: Troponin-I <0.015 14:45 Amylase Level: Interpretation: Normal: Amylase Lvl 69 14:45 Lipase Level: Interpretation: Abnormal: Lipase Lvl 438 15:08 Auto Diff: Interpretation: Abnormal: Neut Abs Auto 10.38 15:23 Gallbladder US: Interpretation: Normal: GB, no wall thickening, no fluid. CBD normal diameter. Will CT abdomen to evaluate aorta and remaining abdominal viscera. 15:39 GFR: Interpretation: Normal: Non AfnAmer GFR >60 16:00 CT: Shows pancreatitis, early necrosis. No hydronephrosis, no stones, no aneurysm or dissection. Assessment: 1. Acute Pancreatitis r/i on CT showing early necrosis, abdominal exam with tenderness upon palpation of right and left hypochrondriac and epigastric regions, abdominal distention, and elevated pancreatic lipase level 2. Myocardial infarction r/o on EKG and normal troponin level 3. CHF r/o with negative BNP, negative history (edema, abnormal heart sounds), negative CXR, and normal EKG 4. Cholecystitis r/o on US 5. Choledocholithiasis r/o on US 6. Hepatitis r/o on CT, LFT labs 7. Gastritis r/o on CT 8. Renal colic r/o on CT and negative history 9. Abdominal aortic aneurysm r/o on CT 10. Peritonitis r/o on CT and abdominal exam without diffuse pain 11. Peptic ulcer disease r/o without relief on Prilosec Plan: Patient requests transfer to Geissinger. Have discussed with internal medicine, Dr. Hergen, who accepts the patient. He will go by ground and be evaluated in the ED there prior to admission. Pain scale upon departure was 3. Treatment for patient w/ pancreatitis: 1. Hospitalization 2. Monitoring vitals pulse ox, blood pressure, respiratory rate, EKG 3. Gastroenterologist and endocrinologist consult and referral 4. NPO for biopsy on necrotic area 5. Dilaudid PRN (After biopsy) 6. IV fluids to maintain BP 7. Low-fat diet 8. NSAIDs 9. Possible pancreatic enzyme replacement therapy (Creon/pancrelipase) 10. Possible surgery to remove necrotic tissue (necrosectomy) or Whipple’s procedure 11. Close follow-up and monitoring with gastroenterologist, endocrinologist, and primary care physician. This would include weekly, monthly, and/or yearly lab testing, enzyme monitoring, US and CT scans. 12. Patient education for pancreatitis includes alcohol avoidance, low fat diet and/or TPN feeding, pain management, fluid hydration, infection prevention, necrosectomy preparation and lifestyle management with enzyme supplementation. Additional education should be provided on diabetes management, hypercholesterolemia management, and HTN/heart comorbidities management. Signature: Candy Hull, PA-S Date: 6/7/12, 20:00