DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSES: Gastroenteropathy, drug induced (CellCept), status post kidney transplant, and hyperkalemia.
PROCEDURES: Colonoscopy and rectal biopsy, CT of abdomen and pelvis, and ultrasound of kidney transplant.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old man with end-stage renal failure who is status post kidney transplant approximately nine days prior to this admission. He was readmitted because of abdominal pain, beginning early on the morning of admission and associated with moving his bowels. There was no bleeding. The pain was generalized at first but then more localized to the suprapubic area, then the right lower quadrant, and later the left upper quadrant. There was no bleeding, fever, chills, nausea or vomiting. There was no previous similar episode. He has been voiding well. There was some serous drainage from the wound. The patient is known to be CMV antibody positive.
CURRENT MEDICATIONS: Prograf and CellCept. He had previous Thymoglobulin induction. He was taking prednisone, Cytovene, Bactrim, Mycelex, clonidine, Norvasc, and Protonix.
PAST MEDICAL HISTORY: Hemodialysis for five years for nephrosclerosis, multiple access failures. Current access, right femoral vein catheter.
SOCIAL HISTORY: No tobacco, alcohol or drugs.
REVIEW OF SYSTEMS: No additional findings.
PHYSICAL EXAMINATION: GENERAL: The patient was alert, in no acute distress. VITAL SIGNS: Blood pressure 116/78. NECK: There was no cervical lymphadenopathy. HEENT: Throat was clear. LUNGS: Clear on auscultation and percussion. HEART: Regular rhythm without a murmur. ABDOMEN: Mildly distended but was soft. There was tenderness in the right lower quadrant and left upper quadrant. The allograft in the left lower quadrant was not enlarged or tender. The staples were in place. Bowel sounds were present. EXTREMITIES: The right femoral catheter exit site was satisfactory. There was no pedal edema.
LABORATORY DATA: An ultrasound of the kidney transplant and bladder were normal. CT of the abdomen was initially interpreted as strong suspicion for ischemic changes; however, the official report was returned as no evidence of abscess or left renal transplant perinephric collection. No abnormality in the bowel was delineated. The patient’s white count was 14,500. His creatinine was 2.7, which was declined.
HOSPITAL COURSE: The patient had persistent abdominal pain. Dr. John Doe was called for consultation and subsequently did a colonoscopy on the patient. There was no narrowing or mucosal change. The patient had persistent diarrhea after the colonoscopy prep. It was felt highly likely that he was having toxicity from the CellCept. This was discontinued and Rapamune was substituted. The patient’s tacrolimus level was low for an early postop patient and the dose was augmented.
He initially had been treated with Levaquin and Flagyl. The Levaquin was discontinued after the colonoscopy. He had abdominal pain of a crampy nature and diarrhea for a couple of more days. The C. difficile was negative; therefore, the Flagyl was discontinued. The biopsy specimen from the colonoscopy showed mild nonspecific chronic inflammation but lymphoid aggregates and mild edema in the lamina propria. The stain for CMV was negative. Diarrhea subsided and abdominal pain subsided. His Prograf level was in the therapeutic range. His creatinine declined to 2.3, and he was discharged.
At the time of discharge, his regimen was prednisone 15 mg b.i.d., Prograf 3 mg b.i.d., Rapamune 5 mg daily, Pepcid 20 mg b.i.d., Bactrim one daily, Mycelex one t.i.d., Cytovene 500 mg b.i.d., clonidine 0.2 mg b.i.d., and Norvasc 5 mg daily. He will be followed up in the transplant clinic.
