Abdominal pain epigastric Unspecified essential hypertension Secondary hyperparathyroidism non-renal Migraine unspecified without mention of intractable migraine without mention of status migrainosus
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: MEDICINE
 
Allergies: 
Patient recorded as having No Known Allergies to Drugs
 
Attending: ___.
 
Chief Complaint:
Abdominal pain
 
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy

 
History of Present Illness:
 Patient ___ yo F with hx of HTN who presented to the ED today 
c/o abd. pain. Pt. states that she has had this pain for 
approximately one month. The pain is epigastric, sharp in nature 
and present throughout the day at a low level, ___, worse in 
the morning with brief attacks ___ per ___, lasting a few 
minutes. It occasionally radiates to the back. The pain is 
worsened with eating solid food but not associated with 
positioning or time of day. The patient saw her PCP ___ ___, was 
started on Prilosec and an H.pylori was checked, which returned 
positive. She was begun on a Prevpac that she states she has 
taken 10 days of. She states that since starting the Prevpac, 
her pain has decreased somewhat with decreased AM pain and 
decreased frequency of attacks. However, her pain has not 
completely abated. Prior to starting the Prevpac, she also had a 
baseline level of constant nausea, intermittent non-bloody 
vomitting, and associated metallic taste in her mouth also for 
one month. She also noted constipation which has transitioned to 
diarrhea since starting the Prevpac. She has no associated 
fevers, blood in her stool, or black stools. Of note she has 
been taking 1000mg of Aleve approximately 3x/week to treat her 
migraine headaches. She states that she has been doing this for 
years. She also notes some minor dysphagia with pills and water 
yesterday, alleviated with drinking more water. Her LMP was ___ 
and she has had regular, normal periods prior. She has never had 
an endoscopy and has been reluctant to get one even at Dr. 
___.  
.  
She has also been undergoing an extensive work up with Dr. 
___ to evaluate her early onset HTN (dx ___, intermittent 
palpitations, flushing, chest pain, headaches, and now abdominal 
pain in the setting of her mother having had a pheochromocytoma. 
Her palpitatoins and chest discomfort have improved 
significantly since starting the atenolol. She has had a normal 
renal MRA, a normal MRI of the abd/pelvis, normal TFTs, normal 
LFTs, normal pancreatic enzymes, normal aldosterone level, 
normal chem 10, normal am cortisol, and a normal u/a. Abnormal 
labs include a borderline elevated urine normetanephrine from 
24hr urine, a mildly elevated PTH, and a borderline elevated 
gastrin level on a PPI. In regards to her head ache, she states 
it occurs 3x/wk, bilateral and pounding in nature, with 
associated photophobia, phonophobia and occasional associated 
blood shot eyes.  
.  
ROS: Positive chills but no fevers. Moderate persistent  
headaches. No visual changes, dysphagia, odynophagia, chest 
pain,  
palpitations, tremor, shortness of breath, wheezing. Positive  
vomiting but no hematemasis, bilious emesis. No melena, blood 
per  
rectum, dysuria, hematuria, arthralgias.  

 
Past Medical History:
Refractory Hypertension  
Low Grade Cervical Intraepithelial Neoplasia  
Migraines  
Depression  

 
Social History:
___
Family History:
Mother with pheochromocytoma 
 
Physical Exam:
Physical Exam:  
VS: T:98.7, BP:175/113, HR:79, RR:14, O2: 98% RA  
GEN: Well appearing, AOx3, NAD  
HEENT: PERRL, EOMI, sclera anicteric, non-injected  
NECK:supple, ? slight increased fullness in L anterior portion, 
does not move with swallowing  
CHEST: CTAB  
CV:RRR, no MRGs appreciated  
ABD:soft, NT/ND, +BS, no masses or HSM noted  
EXT: no edema, no cyanosis, no clubbing, no rashes  
NEURO: strength ___ in all extremities, sensation intact to 
gross.  

 
Pertinent Results:
___ 01:30PM BLOOD WBC-8.6 RBC-4.30 Hgb-12.8 Hct-37.3 MCV-87 
MCH-29.7 MCHC-34.3 RDW-12.8 Plt ___
___ 01:30PM BLOOD Neuts-71.5* ___ Monos-4.9 Eos-0.6 
Baso-0.3
___ 06:40AM BLOOD Glucose-83 UreaN-8 Creat-0.9 Na-138 K-3.8 
Cl-105 HCO3-24 AnGap-13
___ 01:30PM BLOOD ALT-32 AST-23 AlkPhos-65 TotBili-0.3
___ 01:30PM BLOOD Lipase-18
___ 06:40AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9
___ 01:30PM BLOOD Prolact-9.6
___ 01:30PM BLOOD HCG-<5
___ 01:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG 
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

EGD:
Normal Esophagus, stomach, antrum, and duodenum up to the ___ 
portion. 
 
Brief Hospital Course:
Abdominal Pain: The patient was initially admitted for 
evaluation of her abdominal pain. There was a high initial 
suspicion for some form of peptic ulcer disease or gastritis 
given her history and NSAID use. She was continued on her 
Prevpac in hospital with some decrease in her episodes of acute 
pain attacks. However, an EGD showed a totally normal mucosa 
from the esophagus to the duodenum. Her Prevpac was changed to 
Levaquin, Flagyl and prilosec BID as it may be gentler on her 
stomach. She still had intermittent attacks of acute abdominal 
pain but they only lasted ___ minutes, with no time to 
intervene with pain medications. She was able to tolerate solid 
food prior to discharge without significant pain. In discussion 
with her PCP, further work up of her abdominal pain did not 
warrant inpatient evaluation. She will be worked up for 
alternate causes for her pain, including AIP and abdominal 
migraines, as an outpatient. 

HTN: The reason for the patient's hypertension remains unclear. 
It has previously been extensively worked up. The patient was 
evaluated by the endocrine service here who felt that she did 
not have a pheochromocytoma. They recommended a possible repeat 
MRA of the renal arteries in the future for re-evaluation. They 
also recommended outpatient 24hr urines for metanephrines, 
cortisol, DHEA, and free testosterone and a cortisol-stimulation 
test. She already has an outpatient endocrine appointment 
scheduled. She was changed to metoprolol for ease of uptitration 
and was discharged well controlled on 100mg of Toprol XL in 
addition to her lisinopril and HCTZ. 

Hyperparathyroidism: The endocrine service felt that her 
elevated PTH was consistent with secondary hyperparathyroidism 
given her normal calcium. Vitamin D levels were drawn and 
pending at the time of this writing. These will be followed up 
with her endocrinologist.

Migraines: Well controlled with imitriptan.

 
Medications on Admission:
Amoxicill-Clarithro-Lansopraz [Prevpac] - 30 mg-500 mg-500 mg 
(day ___  
Hydrochlorothiazide - 25 mg  
Lisinopril - 10 mg  
Atenolol 50mg  
Sumatriptan - 25 mg Tablet q2 PRN migrain  

 
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once 
a day.  
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 
 
3. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times 
a day).  
4. Imitrex ___ mg Tablet Sig: One (1) Tablet PO q2H as needed for 
pain.  
5. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1) 
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One 
(1) Tablet, Delayed Release (E.C.) PO twice a day. Tablet, 
Delayed Release (E.C.)(s) 
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2 
times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 
24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
9. Compazine 5 mg Tablet Sig: ___ Tablets PO three times a day 
as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*

 
Discharge Disposition:
Home
 
Discharge Diagnosis:
Abdominal pain of unknown origin
HTN

 
Discharge Condition:
All vital signs stable, tolerating POs, pain tolerable

 
Discharge Instructions:
You were admitted with abdominal pain. It is unclear what the 
source of your abdominal pain is but it does not require 
inpatient level of care. You had an endoscopy of your stomach 
which was entirely normal, showing no ulcers or signs of 
irritation or inflammation. You will need to follow up with the 
outpatient stomach doctors to ___ further causes. 

We have changed the antibiotics in your Prevpac to Levofloxacin 
and Flagyll that may be gentler on your stomach. You should also 
continue to take your Prilosec twice a day. 

You were also evaluated by the endocrine service here in regards 
to your high blood pressure. They suggested a number of further 
blood and urine tests. However, these should not be done in the 
stressful environment of the hospital that may alter the 
results. Please be sure to make your out patient endocrine 
appointment with Dr. ___. We have changed your Atenolol to 
Toprol XL, a similar drug, and increased it to better control 
your blood pressure. 

Please call your doctor or return to the emergency room if you 
are unable to keep down food or liquids, have any blood in the 
stool or vomit, have black and tarry stools, have fevers/chills, 
abdominal pain that does not stop after a few minutes, or any 
other symptoms that concern you. 

Please take all your medications as prescribed and attend all 
your recommended follow up appointments.
 
Followup Instructions:
___

{'Abdominal pain': ['Abdominal pain', 'Unspecified essential hypertension', 'Secondary hyperparathyroidism', 'non-renal', 'Migraine', 'unspecified', 'without mention of intractable migraine without mention of status migrainosus'], 'epigastric': ['Abdominal pain', 'Unspecified essential hypertension', 'Secondary hyperparathyroidism', 'non-renal', 'Migraine', 'unspecified', 'without mention of intractable migraine without mention of status migrainosus']}