DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: For evaluation and management of continuous diarrhea.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American male directly admitted with a diagnosis of nausea, vomiting, and dehydration. The patient states that he started having diarrhea, and had more than 10 stools a day. The patient states that his frequency of stool is fluctuating. He states that he did have a reddish stool. The patient’s son states that stool was the color of brown pudding earlier this morning. The patient did not have an appetite; apparently, appetite is improving. He is eating currently. He has not taken any new medication, has not done any recent traveling, has not taken any antibiotics. He denied any abdominal pain. Denied any odynophagia, dysphagia, chest pain, or shortness of breath. Denied any history of constipation. He has denied any GERD symptoms. The patient states that he has never had a colonoscopy.
PAST MEDICAL HISTORY: Significant for acute renal insufficiency, which has apparently progressed to acute renal failure, hypertension, diabetes, hypercholesterolemia, coronary artery disease, peripheral vascular disease, and bowel obstruction.
PAST SURGICAL HISTORY: Significant for vasectomy, CABG, tonsillectomy, and right knee arthroscopy.
SOCIAL HISTORY: The patient does have a history of smoking; he quit 20 years ago. Denies any alcohol usage.
FAMILY HISTORY: Negative for colon and stomach cancer.
ALLERGIES: No known allergies.
MEDICATIONS: Norvasc, Lipitor, glyburide, guaifenesin, Toprol, and Avandia.
PHYSICAL EXAMINATION: Vital Signs: Temperature 98.6 degrees, heart rate 90 beats per minute, respirations 20 breaths per minute, O2 saturation 94%, and blood pressure 112/58. Neurologic: The patient is alert and oriented x3. Heart: S1 and S2. Lungs: Clear to auscultation. Abdomen: Soft and nontender. Positive bowel sounds in all four quadrants. No organomegaly.
LABORATORY DATA: H&H on admission 10.6 and 31.8. Today, H&H is 10.6 and 30.8. White blood cell count 12.6, which is increasing; admitting was 10.4. Platelet count 246,000, bands 31. PT and INR four days back 15.6 and 1.26. Sodium 139 and potassium 2.9. The patient is on potassium protocol; last potassium was 3.2. BUN 60, creatinine 2.1 improving from BUN of 70 with creatinine of 6.2. LFTs two days ago; alkaline phosphatase 70, ALT 34, AST 30. Magnesium 1.8 on admission, amylase 102 with a lipase of 94. Urinalysis did indicate +1 bacteria and 2 to 5 hyaline casts with trace occult blood. Urine culture was unremarkable. Four days ago, fecal white blood cell count was negative. O&P was negative. CDT assay was negative.
DIAGNOSTIC DATA: Last chest x-ray yesterday did show well-ventilated lungs. Abdominal x-ray four days ago showed mild distension of the small and large bowel, possibly representing ileus, nonobstructive pattern. Renal ultrasound three days ago showed normal ultrasound. Renal nuclear medicine scan showed 50% function of the left and 50% function of the right.
IMPRESSION:
1. Diarrhea with bandemia. Etiology is unknown, will be further worked up. Giardia is a possibility and diabetic diarrhea is also a possibility, or multiple other etiologies due to the patient never having a baseline colonoscopy.
2. Nausea and vomiting, which has improved. The patient has not had any emesis today. He is eating, however, is having nausea off and on.
3. Acute renal failure, which is improving.
4. Hypertension.
5. Diabetes.
6. History of coronary artery disease with a coronary artery bypass grafting x3.
7. History of hypercholesterolemia.
8. Peripheral vascular disease.
9. History of bowel obstruction.
PLAN: Plan was reviewed with Dr. John Doe. Dr. John Doe did make rounds on the patient. Stool will be sent for culture, and the patient will have a total CDT of 3; 1 has already been done. Colonoscopy will be scheduled for Wednesday. Today, the patient will be on a clear liquid diet and will be n.p.o. after midnight. We will start 1 gallon of GoLYTELY today. Procedures have been explained to the patient. The patient is in agreement. If nausea or vomiting is not improved, EGD will need to be done to evaluate the patient for peptic ulcer disease or other etiologies. The patient will be started on Protonix 40 mg p.o. q.a.m. Further recommendations will be made pending lab results and colonoscopy findings.
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