Inpatient Consultation
Patient Case Number: IPC05- Findlay, Logan
Patient Name: Logan Findlay | DOB: 03-28-57 | Sex: M
Date of Service: 05-05-XX | Physician: Lincoln Spicer, MD

# Reason for Consult: Abdominal Pain

# History of Present Illness:

Logan Findlay is a 61y/o male with a history of prostate cancer and metastatic bladder cancer with mets to the bone. He is currently undergoing chemotherapy treatment.

Patient underwent prostatectomy, cystectomy, and a bilateral pelvic lymph node dissection with bilateral ureteroileal conduit. Within the past several months patient was diagnosed with a partial small bowel obstruction. Within the last week his abdominal pain has progressively gotten worse and he presented to the hospital. He has not had a bowel movement in 5 days, however he is currently passing gas. Patient says since the NG tube was placed he has been feeling much better, his pain and bloating are both improved.

# Review of Systems:

# General: Metastatic prostate cancer, possible metastasis to omentum according the what patient was told

# ENT: negative

# Eyes: negative.

# Cardiovascular: no chest pain or dyspnea on exertion Respiratory: no cough, shortness of breath, or wheezing Gastrointestinal: negative for - abdominal pain

# Genito-Urinary: positive for -ureterostomy and ureteroileal conduit.

# Neurological: negative Endocrine: negative MS: negative.

# Allergy and Immunology: negative

# Medical History: GERD, seasonal allergies

# Allergy: NKDA

# Medications: Simethicone 125mg, Probiotic caps

# Vitals:

Temperature | 98.6°F
Pulse | 78
Respirations | 20
Blood Pressure | 130/80
SpO2 | 98% on room air

# Physical Examination:

# General: Patient appears in no acute distress

# Heart: RRR

# Lungs: Breathing non-labored

# Abdomen: Soft, non-distended, no pain to palpation

# Extremities: Moving all 4

Labs: CBC and Differential Test |  | Value | Reference Range
WBC |  | 8.2 | 4.0 - 12.0 10*3/uL
RBC |  | 4.92 | 3.50 - 5.55 10*6/uL
Hemoglobin |  | 13.9 | 12.6 - 16.5 g/dL
Hematocrit |  | 40.7 (*) | 42.0 - 49.5 %
MCV |  | 83 | 80 - 100 fL
MCH |  | 28.3 | 27.0 - 33.0 pg
MCHC |  | 34.2 | 31.0 - 37.0 g/dL
Platelet Count |  | 137 (*) | 150 - 400 10*3/uL
Neutrophils |  | 87.6 (*) | 49.0 - 81.0 %
Lymphocytes |  | 5.5 (*) | 14.0 - 41.0 %
Monocytes |  | 6.7 | 0.0 - 11.0 %
Eosinophil Count, Total |  | 0.0 | 0.0 - 6.0 %
Basophils |  | 0.2 | 0.0 - 3.0 %

Absolute Neutrophils | 7.14 | 1.96 - 9.72 10*3/uL
Absolute Lymphocytes | 0.45 (*) | 0.56 - 4.92 10*3/uL
Absolute Monocytes | 0.55 | 0.00 - 1.32 10*3/uL
Absolute Eosinophils | 0.00 | 0.00 - 0.72 10*3/uL
Absolute Basophils | 0.02 | 0.00 - 0.36 10*3/uL

# Comprehensive Metabolic Panel

Test | Value | Reference Range
Calcium | 7.82 (*) | 8.00 - 10.50 mg/dL
Alkaline Phosphatase | 88 | 0 - 120 U/L
Bilirubin, Total | 0.7 | 0.2 - 1.2 mg/dL
Protein, Total | 6.3 | 6.0 - 8.0 g/dL
Albumin | 3.3 (*) | 3.6 - 5.0 g/dL
BUN | 23 | 6 - 23 mg/dL
Creatinine, Serum | 0.75 | 0.60 - 1.40 mg/dL
Glucose | 143 (*) | 65 - 99 mg/dL
AST | 47 (*) | 10 - 40 U/L
ALT | 81 (*) | 2 - 45 U/L
Sodium | 133 (*) | 135 - 145 meq/L
Potassium | 4.3 | 3.5 - 4.9 meq/L
Chloride | 100 | 96 - 110 meq/L
CO2, Total | 22.0 | 20.0 - 30.0 mmol/L
Anion Gap | 11 | 2 – 16
Protime-INR Test | Value | Reference Range
Prothrombin Time | 10.6 | 9.0 - 11.5 s
INR | 1.1 (*) | 2.0 - 3.0
eGFR Test | Value | Reference Range
Non-African Amer. GFR | >90 | >90 mL/min
African Amer. GFR | >90 | >90 mL/min
Radiology |  |

# CT of abdomen/pelvis w/ IV Contrast Impression: Partial small bowel obstruction.

# Assessment:

1. Partial small bowel obstruction; rule out adhesions vs. new left lower quadrant abdominal mass.

2. GERD

3. Seasonal allergies

4. Hx of prostate cancer

5. Metastatic bladder cancer w/ mets to bone

# Plan:

1. No urgent surgical intervention at this time

2. Consult urology given patients extensive urology history and hx of prostate cancer

3. Continue NG tube

4. At some point given patients history of recurring partial small bowel obstruction he will likely need surgery to rule out adhesions vs. mass compromising bowel function.

# Electronically Signed By: Lincoln Spicer, MD

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