DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Hematochezia, drop in hemoglobin.
HISTORY OF PRESENT ILLNESS: The patient is a pleasant (XX)-year-old Asian female admitted with right upper quadrant epigastric pain. On further evaluation, the patient was noted to have cholesterol crystals in the gallbladder and positive HIDA scan and Murphy sign and underwent a laparoscopic cholecystectomy. Bright red blood per rectum yesterday. No abdominal pain. No crampy pain. No fever. No chills. The patient had a colonoscopy performed approximately 10 years ago. No change in bowel habits. No melena. No constipation. No diarrhea before coming to the hospital.
PAST MEDICAL HISTORY: Questionable TIA in the past, bronchial asthma, TEE, cardiac catheterization, and hysterectomy.
SOCIAL HISTORY: No smoking. No alcohol. The patient is divorced with one son. Lives at home.
FAMILY HISTORY: No family history of colorectal cancer.
REVIEW OF SYSTEMS:
HEENT: No headache. No visual disturbances.
CARDIAC: No chest pain.
RESPIRATORY: No shortness of breath.
GASTROINTESTINAL: As in HPI.
GENITOURINARY: Negative.
MUSCULOSKELETAL: Negative.
PHYSICAL EXAMINATION:
GENERAL: Awake, alert, oriented x3, just returned from surgery, complaining of the surgical pain.
VITAL SIGNS: Temperature 97.6 degrees, pulse 76, and blood pressure 110/72.
HEENT: Conjunctivae are clear.
NECK: No JVD.
CHEST: Clear to auscultation.
HEART: Regular rate and rhythm.
ABDOMEN: Soft. Surgical site noted.
EXTREMITIES: No cyanosis, clubbing or edema.
LABORATORY DATA: WBC 11.2, hemoglobin 12.8, hematocrit 38.8. On admission, hemoglobin was 14.4, hematocrit 42.8, platelets 268,000. INR 0.88. Sodium 136, potassium 4.4, BUN 12, and creatinine of 1.1. Bilirubin total normal at 0.4, alkaline phosphatase 108, ALT 122, and AST 80. Iron saturation 33%. Occult blood negative x1.
ASSESSMENT AND PLAN:
1. A (XX)-year-old Asian female with right upper quadrant pain with cholesterol crystals, positive HIDA scan and Murphy sign, status post laparoscopic cholecystectomy.
2. Elevated liver function tests, most likely from inflammation of the gallbladder.
3. Hematochezia secondary to hemorrhoids. Given the stability of symptoms and recent surgery, would plan conservative treatment with serial enzymes, serial hemoglobin checks, and discharge planning. Given her age and the fact that the last colonoscopy was more than 10 years ago, she is due for a colonoscopy.
4. Discussed the risks, benefits, and alternatives of colonoscopy and the consequences of not following up. Follow up in two to three weeks for outpatient colonoscopy and follow up on her liver function test.
Thank you very much for this consult. Will follow the patient along with you.
