DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Gastroparesis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old African-American female directly admitted with diagnoses of migraines, joint pain, and a level 10 headache. The patient states that she has had continuous nausea. Last emesis was on Monday. The patient states that she does not have a lot of emesis, but the nausea is very persistent. She has denied any diarrhea. Her last bowel movement was yesterday, was medium, not hard or diarrhea; it was brown. The patient denied any melena or hematochezia. She is admitting to a lot of epigastric pain. The patient states that her appetite is good, no weight loss. She denied any fever, chills or chest pain. Shortness of breath is present on exertion. The patient states she had a colonoscopy last year, which was unremarkable.
PAST MEDICAL HISTORY: Significant for hypertension, type 2 diabetes which was diagnosed about six years ago, diabetic neuropathy, PVD, depression, rheumatoid arthritis, fibromyalgia, hypercholesterolemia, IBS, migraines, renal insufficiency, and chronic pain.
PAST SURGICAL HISTORY: Significant for amputation of left second and third toe, hysterectomy, and bilateral total knee replacements.
SOCIAL HISTORY: The patient is married and denies any alcohol abuse.
FAMILY HISTORY: Significant for father dying of a brain tumor. Mother is unknown. The patient does have a brother with rheumatoid arthritis.
ALLERGIES: None.
MEDICATIONS: Zyrtec, Cymbalta, enalapril, Lovenox, Premarin, ferrous sulfate, fentanyl patch, folic acid, Neurontin, insulin, Reglan 10 mg q.i.d., morphine, Remeron, Protonix p.o. daily, prednisone, and Zelnorm.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2, heart rate 94, respirations 18, blood pressure 114/74, and O2 saturation is 98%.
NEUROLOGIC: The patient is alert and oriented x3.
HEART: S1 and S2.
LUNGS: Clear to auscultation.
ABDOMEN: Positive tenderness in all four quadrants with positive bowel sounds in all four quadrants. Round and obese.
EXTREMITIES: Positive pulses with several toe amputations.
LABORATORY DATA: White blood cell count 7.6. H&H 9.8 and 30.6; on admission, H&H was 12.4 and 37.8. MCV 89.6 and platelet count 406,000. Last week, sodium 140, potassium 4.5, BUN 15, creatinine 0.7, calcium 9.2. LFTs were unremarkable. On labs from 10 days ago, TSH elevated at 7.84. Iron from five days ago was 39, ferritin 86, TIBC 218, UIBC 180, saturation 18. Cortisol level within normal limits. Antinuclear antibody positive. Urinalysis did show 3+ occult blood 10 days ago.
Chest x-ray from a week ago was clear with no acute pulmonary process. Gastric emptying scan was very delayed with only 50% gastric emptying at the 4-hour mark, 30% emptying and 5% emptying at 30 minutes. At 1 hour, 23% of gastric contents were emptied. MRI of the brain showed some stable old injury or ischemia to the right occipital lobe. No new area of infarctions.
IMPRESSION:
1. Gastroesophageal reflux disease, which is symptomatic.
2. Severe gastroparesis secondary to use of multiple pain medications and diabetes.
3. Hypertension.
4. Diabetes with diabetic neuropathy.
5. History of irritable bowel syndrome.
6. Migraines.
7. Fibromyalgia with chronic pain management.
8. History of renal insufficiency.
PLAN: Plan was reviewed. Pain medications need to be stopped. This is what is causing the delaying of gastric emptying. Even with the use of this much pain medication, gastric pacing would not assist the patient with her symptoms. E-Mycin will be started 250 mg elixir t.i.d. Protonix will be increased to 40 mg q. 12 hours. We will continue to treat and follow the patient with you. EGD is not indicated at this time.
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