DATE OF CONSULTATION: MM/DD/YYYY
CHIEF COMPLAINT: Admitted with diarrhea.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with a past medical history significant for longstanding CHF, that requires IV Lasix, with ejection fraction of 25% with an AICD pacemaker and history of V-tach, status post MIs and chronic AFib. She was also diagnosed with lung cancer six years ago but was not felt to be an operative candidate.
She was admitted earlier this month with CHF and was seen by our service for severe diarrhea with associated leukocytosis. Clostridium difficile toxicity was negative. She was treated empirically with Flagyl, acidophilus, and Protonix was changed to Aciphex, and she improved and was discharged. Unfortunately, at home, she continued to have large volume, loose, sometimes watery, nonbloody stools up to 10 times a day with associated abdominal cramps with no fever, chills, nausea or vomiting. She became increasingly weak and was readmitted. She has had a leukocytosis of 18.2 to 22.8, and CT scan showed diffuse colonic wall thickening. She was started on p.o. vancomycin, IV Cipro and Flagyl.
PAST MEDICAL HISTORY: Coronary artery disease status post MIs; CABG; CHF, ejection fraction 25%; hypertension; AFib, on Coumadin; history of V-tach status post AICD pacer; right pleural effusion; hypothyroidism; history of right lung cancer, inoperable; gout; COPD; and no history of any GI workup.
PAST SURGICAL HISTORY: CABG status post pacer, AICD.
ALLERGIES: NKDA.
HOME MEDICATIONS: IV Lasix, Diovan, Coreg, Aciphex, Synthroid, Aldactone, prednisone, Albuterol, Atrovent, Flagyl, acidophilus, Coumadin and Atarax.
SOCIAL HISTORY: Cigarettes: None. Alcohol: None. She lives at home.
FAMILY HISTORY: Negative for colorectal cancer.
REVIEW OF SYSTEMS: She is short of breath but she is recently better. She is cold all the time, and she had episodes of shaking over the past month.
PHYSICAL EXAMINATION:
VITAL SIGNS: Blood pressure is 82/46, respiration 18, pulse 72, and temperature 98.2.
GENERAL: Oriented x3. Hard of hearing. No apparent distress.
HEENT: Clear and anicteric.
NECK: Supple.
LUNGS: Decreased breath sounds bilaterally. There is no wheezing.
HEART: Irregular regular rhythm.
ABDOMEN: AICD is palpable. Abdomen is soft. Mild right lower quadrant tenderness. Positive bowel sounds.
EXTREMITIES: Trace edema.
LABORATORY AND DIAGNOSTIC DATA: Showed a white cell count of 22.8, hemoglobin 10.2, hematocrit 33.2, platelet count 212, and MCV 76. Serum sodium 136, potassium 3.6, chloride 102, CO2 of 20.8. BUN 86, down from 90. Creatinine 3, down from 3.2. Glucose 120, total bilirubin 0.4, AST 12, ALT 26, and total protein 5.2. Albumin 2.8, alkaline phosphatase 70, amylase 32, and lipase 190. Urinalysis: Positive leukocyte esterase, 1+ blood, many bacteria. CT scan: Diffuse colonic wall thickening, especially the sigmoid and infraumbilical hernia with transverse colon. Her C. difficile came back as positive.
IMPRESSION: The patient is a (XX)-year-old female with severe cardiopulmonary disease who presents with severe diarrhea, dehydration, leukocytosis, abnormal CT scan with diffuse colonic wall thickening who is now Clostridium difficile positive.
PLAN: Therefore, we will:
1. Stop her IV Cipro and Flagyl.
2. Continue her vancomycin 125 mg p.o. q.i.d.
3. C difficile precaution.
4. The patient has refused the flexible sigmoidoscopy in the past and now with the C difficile being positive and multiple medical problems, we do not see any reason to proceed with that.
We will follow along. Thank you very much.
