DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Abdominal pain, abnormal CT scan consistent with colitis. Fever, chills, diarrhea and leukocytosis.
HISTORY OF PRESENT ILLNESS: This is a pleasant (XX)-year-old Hispanic male with no significant past medical history, who presented yesterday secondary to an episode of mucus and pus that leaked at 3 p.m. per rectum. He states, when it occurred, he was watching TV in his normal state of health. He then developed severe fever and chills. Due to significant weakness and fatigue, he then called 911 and was then brought to the emergency room. He also reports that typically after a bowel movement, he does have to go to the bathroom right away and has diarrhea, but this has been ongoing for years. He also complains of abdominal pain generalized throughout his abdomen, though more severe in the right periumbilical region.
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
ALLERGIES: No known drug allergies.
MEDICATIONS: None.
SOCIAL HISTORY: The patient is divorced. He has 2 children. Positive tobacco. Positive alcohol.
FAMILY HISTORY: He denies any GI malignancy. No history of inflammatory bowel disease. His father did have an episode of diverticulitis.
REVIEW OF SYSTEMS: Positive nausea. No vomiting. Positive abdominal pain. Positive fever and chills. Positive diarrhea. No rectal bleeding. No constipation.
PHYSICAL EXAMINATION:
GENERAL: This is a well-developed, well-nourished (XX)-year-old gentleman, in no apparent distress, currently quite comfortable in bed. He has fever at this time.
VITAL SIGNS: Temperature 102.4, pulse 74, respiratory rate 22 and blood pressure 116/62.
HEENT: Sclerae are clear. Conjunctivae are pink. Oropharynx is clear. Mucous membranes are moist.
NECK: Supple. No lymphadenopathy.
CHEST: Clear to auscultation bilaterally, anteriorly.
HEART: Regular rate and rhythm. Normal S1 and S2. No murmurs appreciated.
ABDOMEN: Currently soft and nondistended. He does have tenderness in the periumbilical region as well as right and left lower quadrant, right more severe than left. There is no hepatosplenomegaly or masses noted. No rebound, rigidity or guarding.
EXTREMITIES: No clubbing, cyanosis or edema.
LABORATORY DATA: His CMP reveals sodium 136 and calcium 7.4. Liver function tests, amylase and lipase are all normal. His white count is 13.6, hemoglobin of 15.2 and platelet count of 272. CT scan of the abdomen and pelvis reveals colitis of the ascending, transverse and descending colon. No abscess or free air noted.
IMPRESSION:
1. Abdominal pain.
2. Abnormal CT scan with colitis of the ascending, transverse and descending colon.
3. Fever and chills.
4. Diarrhea.
5. Leukocytosis with bandemia.
PLAN:
1. Await stool studies.
2. If the above is negative, then colonoscopy is indicated.
3. We will check ESR, C-reactive protein and IBD serology.
4. Agree with IV antibiotics. He is currently on Unasyn.
Dr. Doe, thank you very much for allowing us to participate in the care of your patient. If you have any questions, please feel free to give us a call.
