DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Thrombocytopenia.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American female who came to the emergency department secondary to abdominal pain and chest pain. Most of her records were obtained from the chart and nurse secondary to the patient being vent dependent. Her past medical history is significant for hypertension, diabetes, obesity, atrial fibrillation, chronic anticoagulation, and sleep apnea. The patient came to the hospital secondary to acute abdomen and chest pain. On admission, her hemoglobin was 6 and apparently she had been having GI bleeding. The patient was found to have severe abdominal discomfort, subsequently had a colon resection, for which she had perforated cecum. Pathology was consistent with an ischemic bowel. She was admitted for further workup.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: As above.
SOCIAL HISTORY: Negative for smoking, negative for ETOH.
FAMILY MEDICAL HISTORY: Not obtained.
ALLERGIES: PENICILLIN.
MEDICATIONS: See chart.
REVIEW OF SYSTEMS: Not obtained, although no signs and symptoms of bleeding.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure 156/76, pulse 94, respirations 14, and temperature 101.4.
GENERAL: The patient is in vent dependent respiratory failure.
HEENT: Eyes are closed.
NECK: Supple.
LUNGS: Have coarse breath sounds, bilateral.
HEART: S1 and S2.
ABDOMEN: Soft. Does have a dressing to the right upper quadrant without drainage.
EXTREMITIES: Trace generalized edema, bilateral pedal pulses.
NEUROLOGIC: Not obtained.
LABORATORY DATA: Today, white count was 12.4, hemoglobin 12.2, hematocrit 37.4, and platelets 124,000. APTT was 31.8, INR is 1.20. Sodium 154, potassium 2.3, chloride 110, CO2 of 36, BUN 50, creatinine 1.1, and glucose 172.
IMPRESSION:
1. The patient was admitted for peritonitis and intraabdominal abscess, status post colon resection, consistent with ischemic bowel.
2. Thrombocytopenia, which is likely consistent with consumption plus or minus infection, cannot completely exclude disseminated intravascular coagulation. The patient was on prophylactic dose of Lovenox. We will check a HIT antibody.
3. Leukocytosis, which is likely reactive secondary to infection.
RECOMMENDATIONS:
1. We will check a disseminated intravascular coagulation profile.
2. Monitor CBCs.
3. We will do an anemia workup.
4. We will transfuse p.r.n.
5. Antibiotics and cultures per Infectious Disease, and we will continue to monitor.
6. We will also start the patient on prophylactic doses of Arixtra 2.5 mg daily.
Thank you for this consultation. We appreciate the opportunity of participating in the care of this patient. If you have any questions, please do not hesitate to contact us.
