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H & P WRITE UP
H & P Write UpNov 18, 2015Age: 61INFORMANT:
1. PatientPATIENT PROFILE: Pt. R is a 61 y/o Caucasian female with no significant medical history, aside from uterine fibroid developed during her 40s.CHIEF COMPLAINT: Ive had laparoscopic nephrectomy with incarcerated hernia as complication. I then had a surgery to get the complication fixed and has been hospitalized till now. I requested a delayed discharge till Wednesday.HISTORY OF THE PRESENT ILLNESS: Pt. R is a 61 y/o Caucasian female with no significant medical history, who presents to Duke due to a complication of incarcerated hernia following her laparoscopic nephrectomy on the right side. She noticed flu symptoms about 2-3 weeks ago. After going to Duke Urgent Care and did not get better, she went to Duke Emergency where she was diagnosed with Urinary Tract Infection and a mass on her right kidney and was discharged last week of October. On Nov 4, she proceeded with a laparoscopic nephrectomy on the right kidney and went home that Thursday. On Friday evening, patient vomited brilliant green bile. On Sunday, she was back to the Emergency room. A CT scan showed that she had incarcerated hernia where a piece of her intestine slipped through the scar. She mentioned that the reason the hernia did not get caught earlier was because she did not look sick when hospitalized and could walk ten laps around. A procedure was done to save her intestine. She requested a delayed discharge till Wednesday. She denied any weight change. Prior to the surgery, she was more fatigue, had fever, chill, night sweat, burb, diarrhea, pain when throwing up. She currently has full bowel movement. Patient refused morphine and narcotics, and used Tylenol instead. Patient is allergic to Ibuprofen. When using Tylenol, the pain is reduced from 6 or 7 to about 3 or 4 on a 0-10 pain scale.
PAST MEDICAL HISTORY:
1. Patient developed uterine fibroid since her 40sPAST SURGICAL HISTORY:1. No past surgical historyCURRENT MEDICATIONS:
1. Tylenol as neededALLERGIES/SENSITIVITIES:
1. IbuprofenSOCIAL HISTORY: Pt. R is not married and has no children. She currently lives with her mom. She graduated from the PhD program in Electrical Engineering at Stanford, and has since worked in the field of computer sciences. She lives in Durham an retired last year from teaching at North Carolina State University to take care of her elderly mother. She currently works on her own consulting business and is writing a book. She mentioned her church as her support system. The pastors came visit and brought candies to her during her stay at the hospital. She does not smoke, drink and use drugs. She does not drink soda and caffeinated beverages. She likes to walk. Her mother is a pediatrician from Johns Hopkins. Her father is also a pediatrician, deceased. HEALTH MAINTENANCE:
1. Not discussedFAMILY HISTORY:
1. Father deceased.2. Mother has congestive heart failure with edema on lower legs
REVIEW OF SYSTEMSGeneral:
(-) weight change, (+) fatigue, (+) weakness, (+) fever, (+) chills, (+) night sweatsPHYSICAL EXAMINATION:
VITAL SIGNS:
Did not examinedGENERAL: Well nourished, healthy-appearing adultASSESSMENT/PLAN:
Pt. R is a 61 y/o Caucasian female with no significant medical history, who presents to Duke due to a complication of incarcerated hernia following her laparoscopic nephrectomy on the right side.1. Flu symptoms. Began 3 weeks ago. Cause is: a. Mass on right kidney:i. Supported by UTI
ii. Proceeded with laparoscopic nephrectomy on right kidneyiii. Prescribed Tylenol for pain management2. Incarcerated hernia: a. Confirmed by CT scanb. Surgery to resolve c. Monitor patient at hospital until stable condition
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