Gagandeep Munday SOAP #1

Subjective: RM is a 34-year-old female with PMH of HLD presented to the ED with acute onset of 8/10 postprandial RUQ abdominal pain. Pt states that pain is  non radiating, constant, and sharp. LMP was 2 weeks ago. LBM this morning was normal, non bloody. Denies any alleviating factors, nausea, vomiting, fevers, chills, constipation, diarrhea, chest pain, shortness of breath, h/o abdominal surgeries, h/o smoking, h/o drinking.

Objective: Vitals: T 98.3 oral | HR: 97 beats per minute, regular | RR: 18, unlabored | BP: 128/82 | O2: 96% RA Physical Exam General: appears stated age, a&ox3, no acute distress Heart: RRR, S1 and S2 present, no murmurs Lungs: CTA bilaterally, no crackles, rales, ronchi Abdomen: normoactive bowel sounds, no ecchymosis, so surgical scars, non distended, soft, +RUQ tenderness, negative murphys, negative rovsings, negative mcburneys, negative psoas, negative obturator  LE: capillary refill<2, no calf tenderness Labs: CBC: WBC|RBC|Hb|Hct|Platelets      15.78| 4.33| 12| 37.7| 408 BMP: Na|K|Cl|CO2|BUN|Cr|Ca  136| 4.2| 98| 23| 15| 0.45| 9.1 Hepatic: ALP 130 ALT 60 AST 31 total bilirubin: 0.3 Pregnancy test negative Imaging: CT: multiple gallstones and common bile duct normal diameter US: multiple gallstones stones, gallbladder is distended, normal common bile duct diameter

Assessment: 34 year old female presenting with 8/10 postprandial RUQ pain. Objectively pt has tenderness to RUQ with palpation of abdomen, elevated WBCs, and US indicates multiple gallstones, Likely cholecystitis.

Plan: Admit IV fluids and IV Zosyn NPO Laparoscopic cholecystectomy

Gagandeep Munday SOAP #2

Subjective: KR is a 20 year-old male with no significant past medical or surgical history presents to the ED ℅ periumbilical abdominal pain for 1 day. Pt states that pain started last night, and has been a constant 9/10 non-radiating periumbilical pain. LBM yesterday was normal, non bloody. Denies fever, chills, body aches, N/V/D/C, chest pain, SOB, cough, dysuria, and hematuria.

Objective: Vitals: T 97.8 oral | HR: 77 beats per minute, regular | RR: 18, unlabored | BP: 140/74 | O2: 99% RA  Physical Exam General: appears stated age, a&ox3, no acute distress Heart: RRR, S1 and S2 present, no murmurs Lungs: CTA bilaterally, no crackles, rales, ronchi Abdomen: normoactive bowel sounds, no ecchymosis, no surgical scars, soft, non distended, periumbilical tenderness, RLQ tenderness, +guarding, no tenderness in other quadrants, negative murphys, negative rovsings, positive mcburneys, negative psoas, negative obturator LE: capillary refill<2, no calf tenderness  Labs: CBC: WBC|RBC|Hb|Hct|Platelets      11.90| 4.56| 14.6| 42.4| 161 BMP: Na|K|Cl|CO2|BUN|Cr|Ca  138| 4.6| 98| 24| 14| 1.01| 9.5  Hepatic: ALP 77 ALT 14 AST 34 total bilirubin: 0.6  Imaging: CT abdomen and pelvis with contrast: Dilated appendix measuring 1.3cm with appendicolith and periappendiceal inflammatory fat stranding due to acute appendicitis.

Assessment: 20 year old male with 1 day of periumbilical abdominal pain, denies any other associated symptoms. Exam positive for periumbilical and RLQ tenderness, garuding, and positive mcburneys. Labs indicate leukocytosis. CT indicative of appendicitis. Likely acute appendicitis.

Plan: Admit for surgery IV fluids and Cefoxitin, NPO PRN zofran and dilaudid DVT prophylaxis Laparoscopic appendectomy

Gagandeep Munday SOAP #3

Subjective: KR is a 20 year old male s/p laparoscopic appendectomy. Pt was examined lying comfortably in bed, POD#0. States that he recently received his dilaudid and that his pain is well controlled at this time. States that he has been tolerating his clear diet well, voided x4 times without difficulty.  Pt denies any acute or new complaints at this time.

Objective: Vitals: T 98.3 oral | HR: 97 beats per minute, regular | RR: 18, unlabored | BP: 128/82 | O2: 96% RA  Physical Exam General: appears stated age, a&ox3, no acute distress Heart: RRR, S1 and S2 present, no murmurs Lungs: CTA bilaterally, no crackles, rales, ronchi Abdomen: normoactive bowel sounds, non-distended, soft, minimal tenderness to palpation on incisional sites, port sites have mild ecchymosis, no discharge, no surrounding ecchymosis LE: capillary refill<2, no calf tenderness  Labs: COVID test negative Blood Type: O negative INR: 1.0

Assessment: 20 year old male s/p appendectomy 8 hours ago, progressing well.

Plan: Perioperative cefoxitin x2 doses Dilaudid PRN for pain Advance to regular diet in the morning Encourage use of incentive spirometer Sequential compression device, and early ambulation for DVT prophylaxis D/C planned for tomm

Gagandeep Munday SOAP #4

Subjective: DD is a 38 year old male with remote PSH of ventriculoperitoneal shunt x2 in 1984 2/2 congenital hydrocephalus. Reports having constant 6/10 abdominal pain, nausea, and bloating x1 day. LBM yesterday, felt incomplete, small and pasty. Denies fever, chills, body aches, sore throat, cough, chest pain, SOB, h/o abdominal surgeries, h/o malignancy, rectal bleeding, dysuria, hematuria, diarrhea.

Objective: Vitals: T 98.2 oral | HR: 76 beats per minute, regular | RR: 16, unlabored | BP: 125/63 | O2: 97% RA  Physical Exam General: appears stated age, a&ox3, no acute distress Heart: RRR, S1 and S2 present, no murmurs Lungs: CTA bilaterally, no crackles, rales, ronchi Abdomen: normoactive bowel sounds, no ecchymosis, surgical scar to epigastric region, distended, soft, diffuse abdominal tenderness to palpation in all 4 quadrants, no palpable masses LE: capillary refill<2, no calf tenderness, no venous stasis changes, no discoloration, no ulcers  Labs: CBC: WBC|RBC|Hb|Hct|Platelets      8.65| 5.84| 17.2| 51.7| 288 BMP: Na|K|Cl|CO2|BUN|Cr|Ca  141| 4.8| 97| 32| 13| 1.14| 10.1 Hepatic: ALP 121 ALT 25 AST 23 total bilirubin: 0.7  Imaging: Abdominal x-ray: Catheter  extending from right hemithorax into the abdomen that probably represents a VP shunt. Surgical clip overlying abdomen. No free intraperitoneal air. No specific air fluid levels. No dilated loops of bowel. CT abdomen pelvis with contrast: Dilated small loops of bowel with collapsed ileal small bowel loops due to small bowel obstruction.

Assessment: 38 year old M s/p remote VP shunt coming in with diffuse abdominal tenderness and distention. Imaging, signs, and symptoms indicative of an SBO.

Plan: Admit to surgery NG tube Gastrografin challenge  NPO Serial abdominal exams IV fluids Trend lactate

Gagandeep Munday SOAP #5

Subjective: SL is a 66 y/o F with h/o A fib, CAD, hypothyroidism, GERD, HTN s/p mechanical AVR and MV repair on coumadin p/w periumbilical abdominal pain to ED now having RLQ abdominal pain. CT indicative of acute appendicitis and surgery consult was called. Denies fever, chills, body aches, n/v/d/c, chest pain, SOB.

Objective: Vitals: T 103.0 oral | HR: 98 beats per minute, regular | RR: 18, unlabored | BP: 141/72 | O2: 96% RA  Physical Exam General: appears stated age, a&ox3, no acute distress Heart: RRR, S1 and S2 present, no murmurs Lungs: CTA bilaterally, no crackles, rales, ronchi Abdomen: Abdomen: normoactive bowel sounds, no ecchymosis, no surgical scars, soft, non distended, RLQ tenderness, no guarding, no tenderness in other quadrants, negative murphys, negative rovsings, positive mcburneys, negative psoas, negative obturator LE: capillary refill<2, no calf tenderness  Labs: CBC: WBC|RBC|Hb|Hct|Platelets      14.50| 4.59| 12.9| 40.6| 164 BMP: Na|K|Cl|CO2|BUN|Cr|Ca  137| 3.8| 100| 27| 13| 0.91| 8.9 Hepatic: ALP 121 ALT 25 AST 23 total bilirubin: 0.7  PT/INR: 28.8 | 2.4 Imaging: CT Abdomen Pelvis and contrast: Findings consistent with acute appendicitis. Cirrhotic liver with fatty infiltration.

Assessment: 66 y/o F with h/o A fib, CAD, hypothyroidism, GERD, HTN s/p mechanical AVR and MV repair on coumadin p/w periumbilical abdominal pain to ED, now having RLQ abdominal pain. CT indicative of acute appendicitis.

Plan: Admit to surgery Consider abx treatment only vs surgery NPO Zosyn Pain control with Dilaudid Cardiac consult for surgical clearance

Gagandeep Munday SOAP #6

Subjective: DR is a 54 y/o M with PMH of gastric ulcer and right inguinal hernia since 2019 presents with increasing discomfort in RT testicle and suprapubic area. Pt works in construction and routinely lifts heavy objects, two weeks ago he was lifting cinder blocks and felt increased pain in his lower abdomen. Currently he endorses a 3/10 dull pain in the groin with a noticeably visible bulge. Denies any nausea, vomiting, diarrhea, bloating, constipation, rectal bleeding, hematochezia, h/o abdominal surgeries, fever, chills, body aches, CP, SOB.

Objective: Vitals: T 98.3 oral | HR: 88 beats per minute, regular | RR: 16, unlabored | BP: 118/75 | O2: 99% RA  Physical Exam General: appears stated age, a&ox3, no acute distress Heart: RRR, S1 and S2 present, no murmurs Lungs: CTA bilaterally, no crackles, rales, ronchi Abdomen: Soft, non-distended, no tenderness to palpation in all four quadrants. Noticeable swelling to RT groin when patient is standing, with increased protrusion upon coughing. Notable pulsation at tip of finger when inserted into RT inguinal canal. Negative McBruneys, negative rovsings, negative murphys. LE: capillary refill<2, no calf tenderness  Labs: CBC: WBC|RBC|Hb|Hct|Platelets      5.15| 4.74| 14.9| 43.7| 214 BMP: Na|K|Cl|CO2|BUN|Cr|Ca  140| 4.0| 105| 27| 23| 1.19| 9.2 COVID negative

Assessment: 54 y/o M with PMH of gastric ulcer and right inguinal hernia since 2019 p/w worsening dull pain in RT groin with noticeable bulge on visual inspection. Protrusion increases upon coughing. Notable pulsation to tip of finger when inserted into RT inguinal canal. Likely indirect inguinal hernia.

Plan: Consider elective right inguinal hernia repair with mesh vs TRUSS

Gagandeep Munday SOAP #7

Subjective: KS is a 53 y/o male with extensive psychiatric history, currently living in a group home, has past surgical history of umbilical hernia repair and a recent “colon surgery” in the past 3 months. Patient  currently presents to the ED ℅ 7/10 abdominal pain associated with multiple episodes of vomiting and nausea for the past 2 days. Denies diarrhea, constipation, lower back pain, bloody stools, h/o malignancy, fever, chills, body aches, sore throat, cough.

Objective: Vitals: T 98.3 oral | HR: 97 beats per minute, regular | RR: 18, unlabored | BP: 128/82 | O2: 96% RA  Physical Exam General: appears stated age, a&ox3, no acute distress Heart: RRR, S1 and S2 present, no murmurs Lungs: CTA bilaterally, no crackles, rales, ronchi Abdomen: high pitched bowel sounds, no ecchymosis, linear surgical scar above belly button, distended, soft, diffuse abdominal tenderness to palpation in all 4 quadrants, no palpable masses LE: capillary refill<2, no calf tenderness  Labs: CBC: WBC|RBC|Hb|Hct|Platelets      10.31| 4.47| 1379| 41.9| 214 BMP: Na|K|Cl|CO2|BUN|Cr|Ca  138| 4.4| 99| 25| 17| 1.07| 10.1 COVID negative  Imaging: CT Abdomen and Pelvis: Mechanical small bowel obstruction. Transition point is not clearly identified. Surgical clips in the right lower abdomen, indeterminate clinical significance, correlate with surgical history. The colon is not well seen, under distended. No evidence for bowel perforation at this time.

Assessment: 53 y/o M with past surgical history of umbilical hernia repair and colon surgery presents with abdominal pain, nausea, and vomiting x2 days. PE relevant for diffuse tenderness, abdominal distention, and high pitched abdominal sounds. CT indicative of mechanical small bowel obstruction.

Plan: Admit to surgery NPO IVF Patient refused NGT, given gastrografin  Abdominal x-ray to follow up

Gagandeep Munday SOAP #8

Subjective: P.O. is a 61 year old male with past medical history of hyperlipidemia, hypertension, and chronic venous stasis ulcers bilaterally presented to vascular clinic for weekly unna boot change. Denies any acute complaints at this time. Denies fever, chills, body aches, increased discharge, or leg pain.

Objective: Vitals: T 98.3 oral | HR: 74 beats per minute, regular | RR: 16, unlabored | BP: 118/72 | O2: 98% RA  Physical Exam General: appears stated age, a&ox3, no acute distress Heart: RRR, S1 and S2 present, no murmurs Lungs: CTA bilaterally, no crackles, rales, ronchi LE: capillary refill<2, no calf tenderness. Bilateral LE show stasis skin changers, hyperpigmentation, hyperkeratotic skin. LLE has medial ulcers measuring 10×6 cm, 4×5 cm, and 4×3 cm. Anterior shin of LLE has ulcers measuring 3x1cm, 3×2 cm, and 4×1 cm. RLE has a single ulcer measuring 5x6cm. All ulcers are pink and contain granulation tissue. No signs of infection. No calf tenderness.

Assessment: 61 year old male presents with venous stasis ulcers to bilateral LE, requiring change in unna boot.

Plan:  Apply unna boot Continue leg elevation and ambulation Return in one week for unna boot reapplication