H & P Write Up

Nov 18, 2015

Age: 61
INFORMANT:
1. Patient
PATIENT 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 40s
PAST SURGICAL HISTORY:
1. No past surgical history
CURRENT MEDICATIONS:
1. Tylenol as needed

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ALLERGIES/SENSITIVITIES:
1. Ibuprofen
SOCIAL 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 discussed
FAMILY HISTORY:
1. Father deceased.
2. Mother has congestive heart failure with edema on lower legs
REVIEW OF SYSTEMS
General:
(-) weight change, (+) fatigue, (+) weakness, (+) fever, (+) chills, (+) night sweats
PHYSICAL EXAMINATION:
VITAL SIGNS:
Did not examined
GENERAL: Well nourished, healthy-appearing adult
ASSESSMENT/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 kidney
iii. Prescribed Tylenol for pain management

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2. Incarcerated hernia:
a. Confirmed by CT scan
b. Surgery to resolve
c. Monitor patient at hospital until stable condition

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