Patient Case Number Question & Answer Guide (With Explanation)

Understanding this question requires applying core subject principles.

What This Question Is About

This question relates to patient case number and requires a structured academic response.

How to Approach This Question

Break the problem into smaller parts and analyze each logically.

Key Explanation

This topic involves patient case number. A strong answer should include explanation, application, and examples.

Original Question

Patient Case Number: IPC59- Knoch, Armond Patient Name: Armond Knoch DOB: 07-26-66 Sex: M Date of Service: 09-01-XX Physician: Michael Bay, MD Reason for Consultation: Abdominal pain History of Present Illness: The patient is a 52 y/o male that presents with hx ETOH pancreatitis. The patient was admitted on 09-01-XX with acute on chronic ETOH pancreatitis. The patient states the pain never really went away, but over the last 2 days or so, he has had increasing pain, nausea, vomiting. He denies any diarrhea, constipation. Last bowel movement was yesterday. Positive for chills. No GI bleeding. Medical History: Chronic ETOH pancreatitis, hypertension, CAD, old MI, Alcohol dependence Surgical History: Cholecystectomy, abdominal surgery for cholangiocarcinoma. Social History: Drinks 6 cans of beer/day Family History: Negative for cancer of the GI tract. Allergies: NKDA Review of Systems: Epigastric pain radiating to left upper quadrant, right upper quadrant and bilateral back with nausea and vomiting. No GI bleeding. Last bowel movement yesterday. Medications: Subcutaneous heparin Vitals: Temperature 98.5°F Pulse 68 Respirations 20 Blood Pressure 120/66 SpO2 98% on room air Physical Examination: GENERAL: No apparent distress. He is alert and oriented x 3, talking on the phone. HEENT: Normocephalic, facial symmetry. No icterus, no jaundice, no pallor. 6/6/2021 IPC59KnochArmond https://myahima.brightspace.com/content/enforced/6681-VLAB_STUDENTPROTO/PatientCaseScenarios/Inpatient_Consultation/IPC59KnochArmond… 2/2 CARDIOVASCULAR: S1, S2 present. Regular rate and rhythm. RESPIRATIONS: Breath sounds clear to auscultation, bilaterally equal. No dyspnea. ABDOMEN: Bowel sounds quadrant x 4. Nondistended, soft. Moderate epigastric and left upper quadrant tenderness. No organomegaly. No masses palpated. EXTREMITIES: Peripheral pulses present. SKIN: Warm, dry. No cyanosis, no pallor, no jaundice. Laboratory Data: White count yesterday 11.2, today 10.4, hemoglobin 12.4, platelets 281,000. BUN 8, creatinine 0.72, potassium 4.1. Liver chemistry yesterday within normal limits. Lipase is 33. Assessment: 1. Acute on chronic ETOH pancreatitis with exocrine insufficiency. Epigastric pain with referral to pain management for recommendations due to substance abuse issues. 2. Hypertension 3. CAD, history of MI. 4. ETOH dependence, currently drinks 6 cans of beer/day. 5. Mild anemia. Plan: 1. Keep npo for now. Continue IV hydration. Will add proton pump inhibitor and pancrelipase. 2. Monitor CBC, CMP, lipase, check CRP, lipid profile, FOB. 3. Will get CT abdomen and pelvis with contrast. 4. The rest of plan will depend on the findings of above tests. Electronically Signed By: Michael Bay, MD

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