DATE OF CONSULTATION: MM/DD/YYYY
REASON FOR CONSULTATION: Peritonitis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female who was admitted from home for a kidney transplant. Postoperatively, the patient has had delayed graft function. She is receiving Thymoglobulin, CellCept, and Solu-Medrol. She is requiring dialysis via right femoral catheter. On MM/DD/YYYY, she began complaining of severe pain in the right lower quadrant of the abdomen, and positive rebound tenderness was noted. She was felt to have an acute abdomen.
A CT scan of the abdomen showed free intraperitoneal air. The patient had an emergency exploratory surgery this morning for a suspected perforated viscus. The patient had an exploratory laparotomy, repair of colon, diverting colostomy. Ascites fluid was felt to be infected. ID evaluation was requested. The patient is currently in the recovery department. She says she is in a lot of abdominal pain.
PAST MEDICAL HISTORY: End-stage renal disease for 14 years, status post two previous cadaveric-related kidney transplants, history of hypertension, nephrosclerosis, and question of venous thrombosis. The patient had a nephrectomy of the second failed transplant previously, also history of a hysterectomy and history of cervical carcinoma.
CURRENT MEDICATIONS: Solu-Medrol 10 mg IV every 12 hours, CellCept 500 mg IV every 12 hours, Protonix 40 mg once a day, ganciclovir 150 mg after each dialysis, labetalol drip 8 mg a minute. Maxipime 1 gram IV was given this afternoon. The patient has also got 1 gram of vancomycin this afternoon, and Flagyl 500 mg every 8 hours was ordered.
ALLERGIES: None to any antibiotics.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: No alcohol, tobacco or illicit drug use.
REVIEW OF SYSTEMS: No fever, chills or rigors. No head, ears, eyes, nose, and throat symptoms. No shortness of breath, cough, chest pain or palpitations. Positive abdominal pain. No nausea, vomiting or diarrhea. No flank pain. No muscle aches or arthralgias. No headaches or stiff neck.
PHYSICAL EXAMINATION:
GENERAL: The patient is a young Hispanic female who was seen in the recovery room. She was ill appearing and in moderate distress due to abdominal pain. With beginning of morphine infusion, she became much more comfortable.
VITAL SIGNS: Temperature 99.2 degrees, blood pressure 122/92, heart rate 98, respiratory rate 20, and O2 saturation 100%.
SKIN: There was no rash. There were no peripheral stigmata of endocarditis. There was no jaundice.
HEENT: Grossly intact. The patient was already extubated and had a face mask on.
NECK: Supple. No carotid bruits. No thyroid masses.
LUNGS: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Showed a new diverting colostomy. There was a transplant incision in the left iliac fossa. The abdomen was soft, but diffusely tender. Bowel sounds were absent. A dialysis catheter was placed in the right femoral vein.
EXTREMITIES: Lower extremities revealed no cyanosis, clubbing or edema.
NEUROLOGIC: The patient appeared nonfocal.
LABORATORY DATA: From yesterday revealed a white count of 9200, hemoglobin 9.6, and platelet count 122,000. PT 16.2, INR 1.3, PTT 42. Glucose 114, BUN 76, creatinine 9.2, sodium 136, potassium 4.4, chloride 100, and CO2 20.
IMPRESSION: Peritonitis secondary to perforated viscus.
PLAN: Current antibiotic therapy is very appropriate. We will follow vancomycin levels. Continue Maxipime 1 gram IV daily and Flagyl 500 mg IV every 8 hours pending more information.
