Good capture of information and overall well-structured.  As discussed, need a chronologic account of her abdominal issues and complaints so that we can consider all the likely causes for her presenting complaint this time.  Also need more exploration in Hx and PE of the elements likely to change the DDx – see specific comments below.  Lastly, beware of normals in the template that are not actually normal – i.e. report of no soft tissue swelling in LEs after stating that there is pitting edema. 

Identifying Data:

Full Name: S.P.

Age: 72

Sex: Female

Marital Status: Widowed

Race/Nationality: Guyanese

Address: Queens, NY

Date of Birth: XX/XX/1949

Date and Time: 6/28/2021 9:45 AM 

Location: New York Presbyterian Hospital Queens    

Religion: Hindu

Source of Information: Self

Source of Referral: Self

Reliability: Reliable patient 

Mode of Transport: EMS

Chief Complaint: Upper abdominal pain and distention x 6 weeks   

History of Present Illness: 

72-year-old Guyanese female, living with daughter, ambulating without assistance, able to perform her ADLs and IADLs independently, with a PMHx of asthma and HLD, s/p unroofing of right uretocystocele and right ureteral stone extraction on 6/25/2021, who presented to NYPQ ED on 6/27/2021 complaining of constant upper abdominal pain and distention for six weeks. The patient reported that the pain and swelling has worsened since the surgery, with associated shortness of breath secondary to the abdominal swelling That’s the patient’s interpretation (likely correct) Your job is to ask a little more about when and how it happens. Patient also reports decreased appetite and 10lb unintentional weight loss in six weeks. Patient states the pain is sharp, exacerbated at night/lying down and radiates to her back with an 8/10 pain. Patient reported taking nebulizer treatment at home with no relief. Patient reports urinary output from her foley catheter, which she had placed due to urinary retention postop. In the ED, patient had stable vital signs except mild hypertension at 150/85, urinalysis with blood and leukocyte esterase and CT abdominal/pelvis significant for large volume of ascites of uncertain etiology. Patient had a diagnostic paracentesis in the ED with 200 cc of foamy, yellow fluid removed. Foley catheter was removed. Patient received Pepcid 20 mg IV, Zofran 4 mg IV, 1L of normal saline and was started on Zosyn 3.375 mg and admitted to medicine.

 As discussed the sequence here needs to begin with the first change – her abdominal pain 6 weeks ago and the weight loss.  Then her presentation for treatment of that and the subsequent procedure, it’s outcome and her condition on discharge.  Then the story of this presentation to the ED and what was discovered/done and then the following paragraph. 

Currently, patient is hemodynamically stable and resting in her bed. She reports nausea, upper abdominal pain, abdominal swelling, and shortness of breath  (need to know if there is any change in these)but denies fever, chills, chest pain, palpitations, headache, dizziness, hematochezia, vomiting, diarrhea, constipation, or any other symptoms. Patient had a normal bowel movement this morning and she reports she is voiding with no dysuria or hematuria She reports only tolerating minimal PO intake why? – what happens?. She denies a history of abdominal surgeries or small bowel obstructions in the past this belongs earlier since obstruction would be on the differential when she first presented to the ED. She states that prior to six weeks ago, she never had these symptoms before.

Of note, patient had an endoscopy and colonoscopy three weeks ago with biopsies of the duodenum, esophagus, and sigmoid colon all of which were benign and a sigmoid colon polyp removal. Again, belongs with the description of the initial testing and procedure prior to this admission.  The guiding principle is that you want to have all the information that would guide thinking on this admission before you get to talking about the admission itself. 

Geriatric Assessment:

• ADLs: Does not require assistance with bathing, dressing, grooming, ambulating, or transferring
• IADLs: independent
• Home health aid: Does not have a home health aid
• Social support: daughter and family. Speaks with family daily.
• Visual impairment: None
• Hearing impairment: None
• Dental: No dentures. Last exam one year ago.
• Falls: No history of falls and no recent falls.
• Assistive device used: None
• Nutritional concerns: Limited PO intake in the past few days secondary to abdominal pain and swelling.
• Gait impairment: None
• Urinary incontinence: Denies
• Fecal incontinence: Denies
• Depression: Denies
• Health care proxy: Daughter
• Advance directives: Full code

Past Medical History:

• Present illnesses:
  • Asthma – never intubated, last exacerbation three years ago
  • Hyperlipidemia
  • Osteoarthritis
  • GERD
  • Obstructive sleep apnea – not on CPAP
• Past medical illnesses:
  • Nephrolithiasis – 6/25/2021
  • Diverticulitis – 5/6/2021 This also needs to be earlier. Does it fall within the 6 weeks of continuous pain?

Immunizations:

• COVID-19: Received both doses, completed on 3/27
• Influenza: 9/2020
• Tdap: 10/2019
• Zoster: Unknown
• Pneumococcal Conjugate 13-Valent (Prevnar 13): Unknown

Past Surgical History:

• Unroofing of right uretocystocele and right ureteral stone extraction on 6/25/2021 at NYPQ – no immediate complications.
• Bilateral breast biopsy many years ago (>10 does not recall exact time) no complications, benign.

Family History:

• Father – deceased, unknown medical problems. 
• Mother – deceased, ovarian cancer at 78 years old
• Sister – 68, alive, T2DM
• Brother – 75, alive, T2DM, prostate cancer
• Paternal Aunt – alive, breast cancer at unknown age

Medications:

• Symbicort 160-4.5 mcg/act twice a day
• Singulair 10 mg nightly
• Simvastatin 20 mg nightly
• Zyrtec 10 mg daily as needed

Allergies:

• Codeine – rash
• Pollen
• Denies any other food, medication, or environmental allergies.

Social history:

• Widowed, lives with daughter in private home in an elevator building. Five stairs in the entryway of the building. Moved from Guyana to the United States over 30 years ago. Last visit to Guyana was in 2014.
• Former secretary, currently retired. Supported by social security income and her daughter.
• Habits: Denies present or past tobacco use, alcohol use or illicit drug use.
• Recent travel: Denies
• Diet: Healthy diet
• Exercise: Walks around the block three times a week.
• Sleep: Admits to difficulty sleeping secondary to the abdominal pain and swelling.
• Sexual history: Denies being currently sexually active, formerly with one male partner.

Review of Systems: 

General: Admits to decreased appetite and 10 lb. unintentional weight loss. Denies fever, chills, night sweats, fatigue, weakness, weight gain. 

Skin, hair, nails: Denies changes in texture, excessive dryness or sweating, discolorations, pruritis or changes in hair distribution.

Head: Denies headache, dizziness, or head trauma. 

Eyes: Denies blurry vision, double vision, loss of vision, photophobia, pruritus, or lacrimation.

Ears: Denies hearing loss, discharge, tinnitus, ear pain or use of hearing aids.

Nose/Sinuses: Denies nasal congestion, nasal discharge, sinus pressure/pain, or loss of smell.

Mouth/throat: Denies sore throat, bleeding gums, mouth ulcers, voice changes or use of dentures. Last dental exam one year ago.

Neck: Denies localized swelling/lumps or stiffness/decreased range of motion.

Respiratory: Admits to shortness of breath due to abdominal swelling. Denies cough, wheezing, sputum production. 

Cardiovascular: Denies chest pain, palpitations, leg edema, hypertension, irregular heartbeat syncope or known heart murmur. 

Gastrointestinal: Admits to abdominal pain, abdominal distention, and nausea. Denies vomiting, hematemesis, diarrhea, constipation, hemorrhoids, rectal bleeding. Last colonoscopy in March 2021.

Genitourinary: Recent episode urinary retention post procedure Denies dysuria, hematuria, dysuria, hesitancy, flank pain, nocturia, oliguria, polyuria, frequency, urgency, incontinence, vaginal bleeding, or vaginal discharge.

Musculoskeletal: Admits to back pain where in the back? and osteoarthritis in right knee. Denies muscle or joint pain, redness, stiffness, unsteady gait, or deformities.

Peripheral vascular exam: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.

Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions or a history of DVT/PE.

Neurologic: Denies weakness, dizziness, lightheadedness, headaches, sensory disturbances, changes in cognition/memory, LOC, loss of strength, ataxia, or numbness.

Psychiatric/Behavioral: Admits to sleep disturbance. Denies depression, suicidal ideations or seeing a mental health professional.

Physical Exam: 

VS: T 98.1 F, BP 145/79, HR 96 bpm, RR 16, O2 sat 98%, Ht5’2”, Wt 155 lb, BMI 28.48 

Gen: Awake, alert, and oriented, in no acute distress. Well-nourished. Appears stated age. Appears slightly uncomfortable while sitting in bed at approximately 60-degree angle.

Skin: Warm and moist, no rash, bruises, or pallor. Normal skin turgor. Non-icteric skin.

Head: Normocephalic, atraumatic.

Eyes: Symmetric OU. No eyelid swelling, ptosis or lesions. PERRLA. Sclera non-icteric. EOMI. 

ENT: Mucous membranes moist. No erythema or exudates in oropharynx. Uvula midline. Trachea midline, thyroid non-enlarged. No lymphadenopathy. Dentition intact with no obvious caries.

Cardiovascular: Regular rate and rhythm. S1 and S2 with no murmurs. Radial pulses, DP/PT pulses 2+ bilaterally. Capillary refill less than 2 seconds bilaterally. +1 pitting edema to bilateral lower extremities need to say where – is it only in the feet or also in the legs and if so, how high? (e.g. at level of malleoli, 3 inches below the tibial tuberosity, etc.  Typically worst in the most dependent part and then less as you go up.  However if she’s been in bed  a while, it may be worst over the sacrum because that’s the most dependent part. JVD noted with head of the bed at 30 degrees. Measure it – how many centimeters.  And did you lower the bed? It was initially at 60 degrees.  If still at that angle, need to report it.  Like with shifting dullness, the JVD can be assessed throughout the day to determine whether there is improvement without having to repeat an imaging study each time.

Respiratory: No respiratory distress. Mild rhonchi at bilateral lower bases. Non-labored breathing. Normal effort.

Abdomen: Bowel sounds present in all quadrants. Soft, tender in left upper and right upper quadrants with diffuse distention. No CVAT. Need a more thorough abdominal exam since this is likely the site of most interest.  Need shifting dullness, fluid wave, liver span and liver edge texture at minimum. 

Extremities: Full range of motion of all extremities. Strength grossly intact. No soft tissue swelling contradicts statement that there is edema, ecchymosis, atrophy, or deformities.

Neuro: Normal gait. Finger to nose intact. No asterixis.

Labs 6/26:

• CBC: WBC 13.26, RBC 4.19, Hgb 11.0, HCT 34.0, MCV 81.1, MCH 26.3, MCHC 32.4, MPV 10.3, RDW 13.5, PLT 540, neutrophil % 83.3%, lymphocyte % 7.4%, monocyte 8.7%, eosinophil 0.0%, immature granulocytes 0.4%
• CMP: Na 128, K 5.1, Cl 92, CO2 24, BUN 9, Creatinine 0.94, Glucose 112, Ca 9.0, anion gap 12, albumin 3.1, total protein 6.1, total bilirubin 0.3, Alk phos 142, ALT 19, AST 36
• Troponin T <0.010, Pro-BNP 318, Lipase 22, Lactate 1.0
• SARS-CoV-2 RNA Not Detected 
• UA: pH 6.5, color yellow, appearance clear, glucose negative, bilirubin negative, ketones negative, specific gravity 1.020, blood moderate, protein trace, nitrite negative, leukocyte esterase moderate, WBC 7-10, RBC 21-50, bacteria negative, squamous epithelial cells 0-4, hyaline cast 0-4

EKG 6/27:

• Sinus rhythm at 94 bpm. T-wave inversion in aVR. No ST elevations or depressions.

Imaging:

• Chest XR 6/27: No acute pathology
• CT abdomen/pelvis impression 6/27: Large volume of ascites of uncertain etiology. Represents a significant change compared to last exam. No findings suggestive of appendicitis, diverticulitis, or bowel obstruction. Did they comment on pelvic organs?

Differentials:

• Iatrogenic perforation of right ureter secondary to unroofing and stone extraction
• Malignancy of what? (likely sources)
• Congestive heart failure
• Cirrhosis
• Nephrotic syndrome

Assessment/Plan: 

72 y/o female with a PMHx of asthma, hyperlipidemia, s/p unroofing of right ureterocele with right ureteral stone extraction three days ago, who presented with worsening abdominal pain and abdominal swelling. Vital signs were unremarkable except mild hypertension at 145/79, physical exam revealed diffuse distention. CT revealed massive ascites, which is new in comparison to CT from May 2021.

• Ascites of unknown etiology
  • Abdominal distention and pain that started six weeks ago
  • Leukocytosis with neutrophilia
  • S/p diagnostic paracentesis with 200 cc cloudy yellowish fluid. Follow up peritoneal fluid analysis for protein, albumin, cell count and creatinine, gram stain, culture, and cytology.
  • Continue IV Zosyn for empiric treatment of peritonitis
  • Monitor LFTs. Viral hepatitis panel ordered.
  • HIV and Quantiferon ordered.
  • Monitor for fever and WBC.
  • Send urine culture. 
  • Urology consult for suspicion of perforation related to procedure three days ago.
  • Therapeutic paracentesis
• Mild intermittent asthma
  • Resume Symbicort 160-4.5 mcg/act twice a day and Singulair 10 mg nightly
• Hyperlipidemia
  • Controlled on current medications No evidence to support this.  Were lipids done?
  • Resume Simvastatin 20 mg nightly
• DVT Prophylaxis
  • Lovenox
• Diet:
  • Heart healthy, 2 grams sodium, 300 mg cholesterol, medium carbohydrate diet (1800-2000 Kcal)