DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a past medical history of HIV, C. difficile colitis, and PCP pneumonia who came into the ER with two episodes of vomiting, nonbloody and mucousy in nature, and she also had fever of 101.8 degrees. The patient had diarrhea, seven to eight bowel movements per day. The patient also had increase in vomiting with some streaking of dark red blood in the vomit. No headaches, no neck stiffness, no cough, no urinary burning, no flank pain. The diarrhea has become worse now.
PAST MEDICAL HISTORY: HIV since (XX); the patient is taking medications for that, CD4 count 33, which was done three weeks ago. History of PCP pneumonia x2. No history of tuberculosis; last PPD was done one year ago, which was negative. No history of meningitis. The patient has been admitted here five to six times since March for C. difficile colitis. She also has a history of asthma and hypertension, which are controlled with medications. She also had a renal biopsy done two months ago, which showed interstitial nephritis with some nephrosclerosis.
SOCIAL HISTORY: The patient smoked but quit smoking 10 years ago and social use of alcohol.
ALLERGIES: The patient is allergic to penicillin and sulfa drugs.
PHYSICAL EXAMINATION: VITAL SIGNS: On examination, her temperature was 97.4 degrees, pulse 102, respiratory rate 20, and blood pressure 112/68. GENERAL: She was in mild distress. CHEST: Clear to auscultation. HEART: S1, S2 present, regular rhythm and rate. No murmur, gallop or rub. ABDOMEN: Epigastric tenderness present. EXTREMITIES: No edema, no calf tenderness, and no thrush.
LABORATORY DATA: At the time of admission, her labs showed WBC count of 12,800. Sodium 132, potassium 2.9, chloride 96, bicarbonate 18, creatinine 4, and blood glucose of 164. UA was done, which was negative. Negative for urine nitrites and leukocyte esterase negative.
During her stay in the hospital, she had a chest x-ray that showed no infiltrate, no cardiomegaly, and x-ray of her abdomen, which showed no air fluid levels, no free air in the abdomen, which indicates no obstruction. She had a stool examination, which was positive for C. difficile toxin A and B. She also had a renal ultrasound because of the complaint of flank pain, which was consistent with medical renal disease. The biopsy, which was done in May, was consistent with medical interstitial nephritis with nephrosclerosis. It was not HIV nephropathy. She also had a renal nuclear scan, which was consistent with medical renal disease, no hydronephrosis, no obstruction, no extravasation in the surrounding tissue.
Later on, two days before the discharge, she complained of pain in her abdomen. She had an ultrasound of her abdomen done, which showed gallstones with no signs and symptoms of cholecystitis, which was not changed from the previous ultrasound, which was done four months back. She was diagnosed with C. difficile colitis and was treated with Flagyl, vancomycin, rifampin, Sandostatin, and Imodium. She also had electrolyte abnormalities, hypophosphatemia, for which she was given Neutra-Phos, but she refused to take it, so was given K-Phos with IV fluids. She had acidosis for which bicarbonate was supplemented in the IV fluids. Her discharge diagnosis was Clostridium difficile colitis.
Due to pain in the flank, she also had an abdominal ultrasound for the pancreas, which was consistent with mild dilatation of the bile duct and some fatty mass in the pancreas, and amylase and lipase were elevated, but the second day, repeat amylase and lipase were done; the first time, it was 580; the second time, it was 300; lipase was 304. The patient also had a previous history of pancreatitis for which she was admitted in April, in the ICU. The patient was discharged with the diagnoses of C. difficile colitis.
HOSPITAL COURSE: During stay in the hospital, the patient’s condition improved. She had no bowel movements for two days, diarrhea was in control, no vomiting, pain in abdomen subsided, no epigastric tenderness, and she was discharged on stavudine, Epivir, Norvir, Reyataz, vancomycin, Flagyl, Sandostatin, rifampin, Zithromax, dapsone, Diflucan, Xanax, and Protonix. She was told to follow up after discharge, in one week, with Dr. John Doe, who is a nephrologist, and with Dr. Jane Doe in October sometime and also was told to have a CT scan of her abdomen to follow up with the pancreas in one week after discharge with oral contrast and also told to have serum amylase, lipase, and phosphorus before she is seen in one week after discharge and to follow up with one of the doctors, Dr. John Doe or Dr. Jane Doe, if she has any complaints. During the stay in the hospital, the patient’s condition improved, she felt better, and she was discharged.
