Ch. 5 – Expanded chart ED visit 3 (where diagnosis was made)

TRIAGE: Time Seen: 1606 PM.

Arrived-By private vehicle. Historian -patient. History limited by severe pain. Physical Exam limited by severe pain. Note: Previous visits to this facility for similar complaints. No history of asthma or emphysema.

Not a nursing home resident, pregnant or receiving treatment for cancer. No recent alcohol.

Attending Note: I personally interviewed the patient and examined the patient. I have personally reviewed the X-rays.

HISTORY OF PRESENT ILLNESS Chief complaint-ABDOMINAL PAIN. This started just prior to arrival about l hour ago (Husband spoke to patient at work at approx. 1:30pm on the phone and patient was fine Half an hour later, patient’s work called husband and told him that patient suddenly started having excruciating abdominal pain. Patient says this is similar but worse than her splenic infarct one moth ago. Was seen in follow-up in the vascular surgery clinic after splenic infarct and they recommended Chest CT and thromobophillia labs neither of whichever got done.  It is described as sharp and well localized. Quality not described as burning, dull or migrating and it is described as located in the epigastric area and in the upper abdomen. No radiation. At its maximum, severity described as severe and 10 1 10. When seen in the E.D.,severity described as severe and 10 / 10. Modifying factors -Not worsened by anything. Not relieved by anything. She has had nausea. No loss of appetite, vomiting or diarrhea.

The patient has had similar symptoms once previously ( 1 month ago) .

REVIEW OF SYSTEMS

No constipation, black stools, hematemesis, difficulty with urination or pain with urination. No urinary frequency, missed periods, abnormal bleeding, bloody stools or irregular periods. No fever, headache, sore throat, blurred vision or chest pain. No difficulty breathing, cough, joint pain, chills or back pain. All systems otherwise negative, except as recorded above.

PAST HISTORY Diabetes mellitus. Other disease. Splenic infarct lmonth ago secondary to clot. No history of peptic ulcer. No history of gallstones, bowel obstruction, hypertension or hyperlipidemia. Has not had urinary calculi.

Medications: None. Allergies: No known drug allergies.

SOCIAL HISTORY Nonsmoker. No alcohol use or drug use. No recent travel. Is a local resident. Resides in a house. The patient lives with spouse.

FAMILY HISTORY Negative.

PHYSICAL EXAM Appearance: Alert. Oriented X3. Appears to be in pain. Patient in severe distress. Vital Signs: Abnormal -hypertensive; heart rate normal; respiratory rate normal; temperature normal. Eyes: Pupils equal, round and reactive to light. Eyes normal inspection. ENT: Nose normal. Pharynx normal. Neck: Normal inspection. Neck supple. CVS: Normal heart rate and rhythm. Heart sounds normal. Pulses normal. Respiratory: No respiratory distress. Breath sounds normal. Abdomen: Severe tenderness in the upper abdomen. Abdomen soft. No organomegaly. No guarding, rebound tenderness, organomegaly, abdominal distention or mass present. The bowel sounds are not abnormal. Back: Normal inspection. No CVA tenderness. Rectal: Rectal exam normal. Rectal exam nontender. Stool heme negative. Skin: Normal skin color and turgor. Skin warm and dry. No rash. Extremities: Extremities exhibit normal ROM. No lower extremity edema. Neuro: Oriented X 3. No motor deficit. No sensory deficit.

LABS, X-RAYS, AND EKG Abdominal CT: Normal aorta. Normal liver, spleen, pancreas, gallbladder and adrenals. Normal kidneys. Bladder normal. No mass. No free fluid. No bony lesion. Occluded superior mesenteric artery. The abdominal CT was independently viewed by me and interpreted by the radiologist. CBC: WBC 17.5 -moderate leukocytosis. Hgb 27.2 -moderate anemia. HCT 8.3 -moderate anemia. Platelets 905 -marked thrombocytosis. Chemistries: Normal Na -140. Normal K -3.6. Mild base deficit –21. Hyperglycemia-198. Normal BUN -14. Normal Cr -0.6. Urinalysis: Micro: few mucous casts. Urine dipstick positive for glucose

(stronglypositive), ketones (strongly positive) and small protein.

PROGRESS AND PROCEDURES

E.D. Course: 1647. Zofran given for nausea. Dilaudid 1mg IV given for pain.

1653. Patient is stable. Physical exam findings are unchanged. Symptoms betterwith morphine 4 mg IV. CBC, Chern 10, CT chest/abd/pelvic with IV/PO contrast ordered (to eval abd perfusion), U/A (to r/ofor UTI), lactic acid levelordered. Results not back yet. Discussed CT with radiology resident and conveyed my concern that she had mesenteric ischemia given her recent aortic clot and splenic infarct. He recommended PO/IV contrast.

1730. CBC and Chern 10 back. Marked thrombocytosis likely secondary to old splenicinfarcts. Patient still has not been taken back for CT.

1830. Patient re-examined several times in the past hour while awaiting CT scan. Patient reports new bilateral flank pain. BP 175/106. Called CT and asked them to expedite CT.

1848. Pt. is resting. Physical exam unchanged. Still awaiting CT scan.

Pain control moderate with morphine 8 mg and dilaudid 1 mg since ED admission.

1931. Patient back from CT scan. Status unchanged. Awaiting radiology read of CT.

21:43. Went to radiology and reviewed CT with the resident. Patient has occlusion of superior mesenteric artery. Surgery was consulted and patient is being urgently admitted to surgery service. Will go to OR for thrombectomy.

Critical care performed (30 minutes). Time is exclusive of separately billable procedures. Time includes: direct patient care, patient reassessment/coordination of patient care, interpretation of data (pulse oximetry and chest xrays) / review of patient’s medical records, medical consultation/consultation with family regarding care and documentation of patient care.

Consult obtained from surgery. Case discussed. Will see patient in the ED. Consultation performed in ED. Consult note reviewed. Agree with treatment plan. Patient and spouse counseled in person regarding the patient’s stable condition/test results, diagnosis and need for admission and surgery. Old inpatient and clinic records reviewed.

Disposition: Admitted to General Surgery.

CLINICAL IMPRESSION

Acute mesenteric ischemia . Occlusion of superior mesenteric artery.

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