DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES:
1. Severe gastroparesis.
2. Pancreas and kidney transplant.
3. Dehydration.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female with a past medical history of simultaneous pancreas/kidney transplant secondary to insulin-dependent diabetes and severe gastroparesis, who presents with a chief complaint of nausea and vomiting. Vomiting occurred more than 25 times prior to coming to the ER and became bloody. The blood was noted to be dark in color. There was no fever or chills, no diarrhea or constipation. She denied melena or bloody stools.
PAST MEDICAL HISTORY: Insulin-dependent diabetes mellitus diagnosed at age 9, no insulin requirement since pancreas transplant, simultaneous kidney/pancreas transplant with bladder drainage, baseline creatinine 1.5, gastroparesis requiring multiple hospitalizations in the past, CMV esophagitis treated last year, hyperlipidemia, osteoporosis, end-stage renal disease secondary to diabetes mellitus, on hemodialysis for three years prior to transplant, and hypothyroidism.
PAST SURGICAL HISTORY: Kidney/pancreas transplant and bilateral hip replacements last year secondary to osteoporosis.
MEDICATIONS: The patient was on Rapamune 1 mg daily, Prograf 1 mg in the a.m. and 0.5 mg in the p.m., prednisone 5 mg daily, Protonix 40 mg daily, Synthroid 0.088 mg daily, Lipitor, Fosamax, sodium bicarbonate 650 mg four times daily, and domperidone.
PHYSICAL EXAMINATION: VITAL SIGNS: The patient was afebrile. Pulse 94, respirations 26, BP 154/76, and O2 saturations 96% on room air. GENERAL: She appeared awake, alert, and oriented x3. The patient was actively vomiting coffee-ground emesis. HEENT: PERRLA. No conjunctival pallor. Sclerae anicteric. Mucous membranes dry. Cracked mouth and lips. NECK: No lymphadenopathy. No JVD. LUNGS: Clear to auscultation bilaterally. HEART: Regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops. ABDOMEN: Normoactive bowel sounds. Nontender and nondistended. EXTREMITIES: No clubbing, cyanosis or edema.
LABORATORY AND DIAGNOSTIC DATA: Sodium 138, potassium 4, chloride 112, CO2 of 12, BUN 40, creatinine 1.7, glucose 140, and calcium 10.6. Total bilirubin was 0.2, alkaline phosphatase 88, AST 24, and ALT 19. White count 14,200, hemoglobin 15.6, hematocrit 49.2, and platelets 222,000. Amylase 120 and lipase 39. UA negative for glucose, ketones, and nitrites. Large leukocyte esterase, 5 wbc’s and 3 rbc’s. Hemoglobin A1c was 6. Chest x-ray showed no infiltrates. Abdominal x-ray showed normal bowel gas pattern, no obstruction.
HOSPITAL COURSE: The patient was treated with IV fluids, Zofran, and Reglan around the clock. Her hemoglobin was closely monitored, which remained stable. She went for an EGD on hospital day #2, which found esophagitis and a possible small Mallory-Weiss tear, as well as a large fluid-filled stomach, which was drained.
Blood cultures, urine cultures, and CMV titers were all negative. The patient required a Zofran drip and higher doses of Reglan, as well as erythromycin before she started to feel better. Her kidney function remained stable. Upon discharge, the patient felt better with no nausea or vomiting and was referred for the placement of a gastric pacemaker for treatment of severe gastroparesis.
