Date: 6/27/2023

Full Name: C.C

Address:  NY, NY

Date of Birth: 8/1/1982

Location: Woodhull Hospital

Source of Information: 

Reliability: Reliable

Source of Referral: Self

S

HPI: CC is a 40-year-old male with no PMHx who presented to the ED on 6/26/2023 with 3-day history of abdominal pain. He reports abdominal pain located to the umbilical area radiating to the generalized abdomen, pain is intermittent, colicky, and 7/10 in terms of severity. It is exacerbated with meals, and no reliving factor. He states that he had multiple episodes of non-bilious vomiting and is endorsing nausea. Patient notes he drinks alcohol twice a month and it’s usually anywhere between 2-3 beers. Patient last intake of alcohol was 7 days ago 2 bottles of beer. He denies any drug use but endorses smoking cigarettes several days a week for several years. He denies any diarrhea, constipation, chest pain, shortness of breath, fever, chills, and dysuria. He denies sick contact, and recent travel.

PMHx: None

PSHx: None

Medication: None

Allergies: NKDA. Food allergy (shelf-fish) reaction Hives

FHx: Non-Contributory

Social History: Drinks alcohol twice a month on average, smokes cigarettes occasionally, sexually active with girlfriend no protection.

ROS: Endorses abdominal pain, nausea, and non-bilious vomiting. Denies diarrhea, constipation, chest pain, shortness of breath, fever, chills, and dysuria.

O:

Vitals:

Vitals: T: 98.2°F (36.8° C) oral | P: 70 BPM, regular | RR: 18 breaths/min, unlabored | BP: 106/65 mm Hg | SpO2: 96% room air | Wt: 170 lb (77.1 kg) |

Physical Exam:

General: laying in bed in no acute distress, Aox3

HENT: Normocephalic and atraumatic, PERRLA and extraocular movements intact. Moist and pink oropharynx.

CV: RRR. S1 and S2 normal. No murmurs.

Pulmonology: No respiratory distress, breathing comfortably on room air, no accessory muscle use

Abdomen: Generalized epigastric tenderness, and negative Murphy sign. Bowl arounds are present x4, and abdomen is soft.

Pertinent Labs:

Lipase: 1,827

Alk Phos: 220

ALT: 625

AST: 352

Total Bilirubin: 4.9

Imagining:

CT Abdomen of Pelvis with IV contrast

Impression: Marked peripancreatic Fluid and fat stranding suggestive of acute pancreatitis, no evidence of intra or extrahepatic ductal dilation

U.S of Liver:

Impression: Evaluation of pancreases is limited. There is cholelithiasis. No significant dilation of the bile ducts

A:  40-year-old male with no PMHx with 3 days of abdominal pain endorsing nausea, and vomiting. On physical exam patient was found to have epigastric tenderness. Patient has high lipase. CT abdomen significant for pancreatitis.

P:

• NPO, advance diet as tolerated.
• IVF maintenance while NPO
• Pain control: Morphine IV PRN
• Zofran PRN for vomiting and nausea.
• Low molecular weight heparin for DVT prophylaxis
• Routine CBC & CMP labs,
• Cholecystectomy scheduled for 6/29/2023