Name: ………………………………………………….….……..

DOB: ………………………………. Gender: …………….

MRN: …………………………….. NOG: …………………
Adm. Date: …………………… Bed: …………….......
Physician: …………………………………………………..….
Coverage: ……………………………………………………...
Resident Admission Note
DATE: Thursday, September 17, 2020 TIME: 15:32 a9/p9
CHIEF COMPLAINT: Diffuse abdominal pain of 1 day duration
HISTORY: Case of 67 years old lady known to have HTN, DL , DM2 . OSA., Gerd , CKD (cr;2.3??) HFpEF , hx of
recurrent sbo obstruction s/p multiple surgeries , presented with diffuse abdominal pain since today , compressing
in nature , constant , mostly epigastric, non radiating , no nausea , 1 episode of induced vomiting , took Tylenol +
Librax with no improvement , , she passed stool and flatus today, no change in bowel habits.
Patient also complains of dyspnea exacerbated by exertion that is worsening since 5 days , she was admitted 6 days
ago and was given Lasix in hospital with some relief and dc on Lasix prn , today she took 2 tabs Lasix 40mg after
contacting her physician , she also reports othorpnea + PNDs , no fever no chills no cough , no chest pain reports 30
pounds weight gain , no other complaint
Patient received Lasix 100mg iv once in ER
PMH: HTN, DL
DM2
OSA.
Gerd
CKD (cr;2.3??)
HFpEF
PSH: Cholecystectomy
TAHBSO
SBO surgery ? x7

Allergies: Pethidine
Medications:
Lipitor 40mg OD
Exetemibe 10mg OD
Cipralex 20mg OD
Bisoprolol 5mg OD
Olmetec(olmestartan) 20mg OD
Pantoprazole 40mg Bid
Tresiba 20 IU sc OD
Dexipron 50mg OD
Lasix 40mg 2 tabs OD Prn
Caltrate 600mg Bid
Alkanorm 1g Bid
Amlor 5 mg OD

SH: past smoker

Non alcoholic
ROS:
Constitutional: Denies fever, chills, weight loss or weakness
HENT: Denies sore throat or ear pain
Respiratory:  Denies cough , rhinorrhea
Cardiovascular:  Denies chest pain, palpitations , reports lower extremity edema
GI:  denies diarrhea. melena, hematochezia
GU: Denies dysuria, polyuria, hematuria, flank pain
Neurologic:  Denies headache, focal weakness or sensory changes, reports tremor since 2 months

TEMPERATURE: 36.3 SPO2: 96% PULSE: 81 BP: 178/79 HEIGHT: WEIGHT: 95Kg
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MR F-10 Ed.7
 Name: ………………………………………………….….……..
GENERAL APPEARANCE: in pain DOB: ………………………………. Gender: …………….
NEURO: Alert & oriented x 3, normal motor function, normal sensory function, no focal MRN:
deficits……………………………..
noted. NOG: …………………
HEENT/NECK: Norm cephalic, atraumatic, oropharynx moist, no oral exudates, Nose normal. Neck- normal range Bed:
Adm. Date: …………………… …………….......
of motion
Physician:bilateral
LUNGS/HEART: Normal heart rate, normal rhythm, no murmurs, no rubs, no gallops. Decreased …………………………………………………..….
air entry , bibasilar
crackles Coverage: ……………………………………………………...
ABDOMEN: Bowel sounds normal, Soft, Diffuse tenderness mostly on the epigastric area, no pulsatile masses.
GENITO-URINARY: No CVA tenderness
SKIN: Warm, dry, no erythema, no rash
OTHERS: bilateral lower extremity 2+ pitting edema

Resident Admission Note (Continued)

DIAGNOSTIC TESTS:
13
WBC 11.98 SODIUM
4
RBC 4.22 POTASSIUM 5.8
10
HGB 10.1 CHLORIDE
4
HCT 32.1 CO2 17
MAGNESIU
MCV 76 2.6
M
17
MCH 24 UREA
8
CREATININ 3.2
MCHC 31.6
E 6
CHCM 31.8
RDW 14.9 CALCIUM 8.5
PHOSPHOR
HDW 2.7 6.9
US
PLT 295 LIPASE 100
MPV 6.5 SGPT 21
LACTIC
%NEUT 78.2 0.84
ACID
DIRECT BILIRUBIN 0.1
INDIRECT BILIRUBIN 0.2
TOTAL BILIRUBIN 0.3
BNP 402
CKMB 3
TROPONIN T 18
U/A: 2-4 WBC , 18-20 RBCs , amorphous urate + , protein 500 , ph 5
CXR : congestion + bilateral effusion
EKG : sinus rhythm , no acute changes
CT Abdomen – Pelvis w/o contrast:

Page 2 of 3
MR F-10 Ed.7
 Name: ………………………………………………….….……..
DOB: ………………………………. Gender: …………….
MRN: …………………………….. NOG: …………………
Adm. Date: …………………… Bed: …………….......
Physician: …………………………………………………..….
Coverage: ……………………………………………………...
Resident Admission Note (Continued)
IMPRESSION: Case of 67 years old lady known to have HTN, DL , DM2 . OSA., Gerd , CKD (cr;2.3??) HFpEF , hx of
recurrent sbo obstruction s/p multiple surgeries presenting with diffuse abdominal pain + worsening dyspnea:
r/o intestinal obstruction
r/o pancreatitis
r/o decomponsated HF
AKI on top of ckd : BUN/Cr: 25 with AG: 13 + electrolyte distubances
R/o Cardiorenal syndrome vs progression of CKD

MANAGEMENT PLAN: IV Bicarb minimal hydration

Accurate in/out + daily weight
Follow up CT Abdomen pelvis
Consult nephro
Resume home meds except olmetec
Give Lasix 40mg po 2 tabs OD
Heparin 5000 bid for dvt prophylaxis
Give duphalac + Kyaxelate for hyperkamlemia
Follow up chem 9 tomorrow

RESIDENT NAME & SIGNATURE: Ali Dakroub PGY1 DATE 9/17/2020 TIME:15:32 a9/p9

ATTENDING NAME & SIGNATURE: DATE TIME

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MR F-10 Ed.7