Chief Complaint: “abdominal pain” x1 day

History of Present Illness:

59 year old F with history of HTN, DM, hysterectomy in 2004 presents with abdominal pain for 1 day. Intermittent pain in epigastric region began upon waking up 1 day ago is described as 10/10, sharp, and stabbing. Pain does not radiate. Tried drinking tea which made pain worse. Associated with 3 episodes of vomiting described as bitter tasting and yellow, no blood. Cooks all food at home, does not eat out. Denies trauma, alcohol use, fever, chills, weight gain or loss, CP, SOB, palpitations, diaphoresis, nausea, diarrhea, constipation. Last BM this morning, described as normal.

Past Medical History:

HTN

DM type 2

Uterine fibroids

Childhood illnesses – denies any significant childhood history

Immunizations – Received flu vaccine

Screening tests & results – Never had colonoscopy. Last eye exam 3 months ago, does not wear glasses. Dental exam 2 years ago, no dentures.

Past Surgical History:

Total hysterectomy, 2004 – no complications

Stripping and ligation of varicose veins in R leg, 2017 – no complications

Denies appendectomy, cholecystectomy, cataracts

Medications:

Amlodipine 10 mg PO daily

Lisinopril 20 mg PO daily

Levemir 100 units/mL subq QHS

Miglitol 100 mg PO TID

Sitagliptin-metformin (janumet) 50-1000 mg PO BID

No recent changes in medications

No vitamins, herbal teas or supplements

Allergies:

NKDA

No known environmental allergies

No known food allergies, no shellfish or seafood allergies

Family History:

Mother-HTN, afib, uterine cancer. Alive and well age 79

Father- DM. Deceased

Maternal Aunt – uterine cancer

Maternal uncle – prostate cancer

Son – DM, CKD on HD. Age 39

Son – No known medical conditions. Alive and well. Age 29

Social History:

Mrs. W is a married female living in a house with her husband.

Habits- Does not drink alcohol. No current or past tobacco smoking. Denies history of substance abuse or illicit substance use. Drinks 4 cup of tea per day.

Travel-No recent international travel

Diet- Stopped eating meat 2 months ago. Breakfast: Tea. Lunch & Dinner: Vegetables, salad, fish.

Exercise-Walks daily

Sleep-Sleeps 4 hours per night

Sexual history- Not sexually active. Denies history of STIs.

Review of Systems:

General-See HPI

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies headache, vertigo, head trauma

Eyes – Denies changes in vision

Ears – Denies deafness, pain, discharge, tinnitus. No hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam 2 years ago, no dentures

Neck – Denies swelling, lumps, decreased ROM

Pulmonary system – See HPI

Cardiovascular system –See HPI

Gastrointestinal system-  See HPI

Nervous –Denies seizures, loss of consciousness, sensory disturbances, ataxia

Musculoskeletal– Denies muscle/joint pain, deformity, swelling, redness, arthritis

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

Hematological system –Denies bleeding, easy bruising, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric – Denies depression/sadness, anxiety, OCD or ever seeing a mental health professional.

Vital Signs

BP:  Seated 154/85

HR: 67 BPM, regular

RR: 18 breaths/minute, unlabored

Temp: 97.7 degrees F orally

O2 Sat: 98% on room air

Physical Exam:

General: Well groomed female, non-toxic appearing, in no acute distress. Alert and oriented x3. Appears stated age.

Skin:   warm & moist, good turgor. Nonicteric, no lesions, scars, tattoos.

Hair:   average quantity and distribution

Nails:   no clubbing, capillary refill <2 seconds throughout.

Head: normocephalic, atraumatic, non tender to palpation throughout

Eyes – symmetrical OU; no evidence of strabismus, exophthalmos or ptosis; sclera white; conjunctiva pale.   PERRLA, EOMs full with no nystagmus  

Nose – symmetrical. No masses, lesions, deformities, trauma or discharge. Nares patent bilaterally. Nasal mucosa moist

Lips –  Pink, moist; no cyanosis or lesions.  

Neck – Nontender to palpation. Trachea midline.   No masses; lesions; scars; pulsations noted. no palpable adenopathy noted.

Thyroid – Non-tender; no palpable masses; no thyromegaly; no bruits noted.

Chest – Symmetrical, no deformities, no evidence trauma. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted.  Lat to AP diameter 2:1.   Non tender to palpation.

Lungs – Clear to auscultation and percussion bilaterally, no adventitious sounds.

Heart:   Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmurs, S3 or S4. No friction rubs appreciated.

Abdomen: Abdomen soft, nondistended, tender to light palpation in epigastric region with involuntary guarding. Bowel sounds normoactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Tympanic throughout, no rebound noted. No hepatosplenomegaly or CVA tenderness appreciated. Negative Murphy’s sign.

Musculoskeletal: Normal range of motion, moving extremities freely, 2+ radial, DP, PT pulses.

Assessment:

59 year old F with history of HTN, DM, hysterectomy in 2004 presents with stabbing, nonradiating, intermittent epigastric pain for 1 day.

Plan:

1. Epigastric abdominal pain
   1. r/o ACS vs drug induced pancreatitis vs cholecystitis vs SBO
   1. EKG showed NSR rate 94, troponin <0.010
   1. NPO, liquid diet as tolerated
   1. IV hydration, analgesia prn
   1. Monitor electrolytes
   1. Lipase 208
   1. CT abdomen and pelvis showed acute uncomplicated pancreatitis
2. DM 
   1. Monitor blood glucose
   1. Hold Janumet (due to sitagliptin)
3. HTN
   1. continue current regiment