DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Acute diverticulitis.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic male who developed acute abdominal pain, mostly on the left side, three days ago. He had fever of 103 and hence came to the emergency department. A CAT scan revealed acute diverticulitis. The patient was started on IV Zosyn, gentamicin, and Flagyl. His fevers have defervesced. He has liquidy stools today. His abdominal pain is somewhat better. He is still on clear liquid diet. He previously had an episode of diverticulitis in August when he took antibiotics for a couple of days with full recovery but did have intermittent abdominal pain.
PAST MEDICAL HISTORY: Gout, hypertension, and hyperlipidemia.
PAST SURGICAL HISTORY: Unremarkable.
ALLERGIES: No known drug allergies.
MEDICATIONS: The patient is currently on allopurinol, Diovan, and Lipitor. He is also on gentamicin, Zosyn, and Flagyl.
SOCIAL HISTORY: Unremarkable.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: As per HPI, otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6 degrees, pulse 92, respirations 18, and blood pressure 132/84.
HEENT: Unremarkable.
NECK: No lymphadenopathy.
LUNGS: Clear to auscultation.
HEART: S1 and S2, regular rhythm.
ABDOMEN: Distension. Bowel sounds faint. The patient has left lower quadrant tenderness with mild rebound tenderness.
EXTREMITIES: No edema, clubbing or cyanosis.
NEUROLOGIC: No focal neurological deficits.
LABORATORY DATA: White count 11.4, hemoglobin 13.6, and platelets 152,000. BUN and creatinine 10.2 and 1.2. CT abdomen shows acute sigmoid diverticulitis without abscess formation or perforation.
IMPRESSION:
1. Acute diverticulitis, second episode. There is no abscess formation or any evidence of perforation; although, he does have mild rebound tenderness.
2. History of gout.
3. History of hypertension.
RECOMMENDATIONS:
1. We would arrange for PICC line and home IV antibiotics. To simplify, we will give Rocephin once a day plus Flagyl orally. We will need at least 7-10 days of IV antibiotics.
2. If any clinical worsening, will need surgical intervention.
3. The patient will eventually need colonoscopy in about 6-8 weeks with modification of diet. Discussed with the patient and his wife. We also discussed this with Dr. John Doe.
Thank you for referring this patient to us.
