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Original Question
LOCATION: Hospital Emergency Department PATIENT: Gladys Winter PHYSICIAN: Paul Sutton, M.D. CHIEF COMPLAINT: Weakness. SUBJECTIVE: This is a pleasant 89-year-old female who says her blood pressure was a little low this morning, 80/40. She got a little bit dizzy. She has had some bloating. Appetite has been decreased. Has had some diarrhea. She gets p.r.n. caths. Has a history of Clostridium difficile. She has also had some vomiting. Again, has had lots of diarrhea. Feels generally weak. Again, her abdomen has been distended. She had Clostridium difficile in January of this year. There are no other associated symptoms. PAST HISTORY: 1. Renal insufficiency. 2. Hypothyroidism. 3. Positive Clostridium difficile. 4. Hypertension. 5. Diabetes. 6. C-section. MEDICATIONS: MR reviewed. ALLERGIES: 1. CODEINE. 2. PENICILLIN. FAMILY HISTORY: Noncontributory in this 89-year-old. REVIEW OF SYSTEMS: Again, remarkable for weakness, vomiting, diarrhea, mild abdominal pain. No shortness of breath. No cough. Ophthalmologic, otolaryngologic, cardio, musculoskeletal, skin, neuro, endocrine and lymphatic all reviewed and otherwise completely negative. SOCIAL HISTORY: Patient does not smoke or drink. She is widowed and has 5 children, 4 boys and a girl. One son passed away 3 years ago in a motor vehicle accident. PHYSICAL EXAM: VITAL SIGNS: Temperature 36.5 degrees, pulse 81, blood pressure 122/67, saturations 97%. GENERAL: On exam, she is alert and oriented. HEENT: Oropharynx dry. No lesions. Pupils equal and reactive to light. Extraocular muscles are full. NECK: Without JVD. Carotids are equal. CARDIOVASCULAR: S1, S2. Grade 2 systolic murmur. No S3, S4. LUNGS: Clear. No rales or rhonchi. ABDOMEN: Soft, diffusely tender, but no rebound, rigidity, or guarding. EXTREMITIES: Free of clubbing or edema. SKIN: Warm and dry. NEUROLOGIC: Cranial nerves intact. Strength 5/5. PSYCHIATRIC: Judgment and insight are excellent. HOSPITAL COURSE: An EKG was completed and reviewed by me. Significant amount of artifact was noted. It was in atrial rhythm. Poor R wave progression, stress of an old anterior infarct. Urine showed 2-5 red cells, 5-8 white cells, otherwise negative. White count 12,000, hemoglobin 15. Platelets were adequate. Basic metabolic panel remarkable for elevated BUN and creatinine, 29 and 1.7, respectively (relatively recently 9 and 0.8, respectively). Electrolytes were relatively reasonable. Alkaline phosphatase at twice normal to 29. She was slightly acidotic with a C02 of 18.5. Her troponin was negative. Flat and upright of the abdomen reviewed by me showed multiple air fluid levels on the lateral decubitus film. Noted was a partial bowel obstruction. ASSESSMENT: 1. Dehydration. 2. Azotemia, likely secondary to #1. 3. Partial bowel obstruction. PLAN: I did start some saline 200 an hour. I did obtain a couple blood cultures. I notified Dr. Green, who was on call, who graciously agreed to assume care, and the patient has been admitted. Help with the codes [please]
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